ASHEVILLE STRATEGIC ALLIANCE
APPLICATION FOR PROFESSIONAL MEMBERS

Completion of this application is considered to be Provisional Acceptance as a Professional Member of the Asheville Strategic Alliance. If the Applicant is approved for full Professional Membership, the applicant will be notified by an ASA member.

For further details and clarification about all aspects of the ASA and its opportunities, please contact an ASA founding member.

Please complete the following form, and mail, fax, email or hand-deliver to the ASA, located at 149 South Lexington Avenue, Asheville, NC 28801; Tel: 828-210-8773; Fax: (828) 258-1031; Email: One of the ASA founding members.

Name of Applicant:

First Name:

______________________________________________

Middle Name:

______________________________________________

Last Name:

______________________________________________

Date of Birth: _________________________________

Driver’s License Information:

License Number: _______________________________

State of Issue: ________________________________

Issue Date: ___________________________________

Expiration Date: _______________________________


Mailing Address:

______________________________________________

______________________________________________

______________________________________________

Business Address (if different from mailing address):

______________________________________________

______________________________________________

______________________________________________

Phone Numbers:

Work: ________________________________

Home: _________________________________

Mobile: _________________________________

Facsimile: _______________________________

Additional Contact Information:

Email Address #1:

_______________________________________________

Email Address #2:

________________________________________________

Website URL #1:

________________________________________________

Website URL #2:

_________________________________________________


Sponsoring ASA Member:

_________________________________________________


Requested ASA Category: (check one)

o Lending and Credit
o Legal Services
o Insurance Servicces
o Accounting and Taxes
o Financial Planning and Investing
o Financial Social Work and Counseling


Applicant's Specialty/Profession:

________________________________________________

Applicant's Professional Designation
(and Professional License Number and State, if applicable):

________________________________________________

________________________________________________

________________________________________________


PRIOR TO ACCEPTANCE AS A PROFESSIONAL MEMBER…

* I hereby acknowledge and give permission to the Asheville Strategic Alliance to conduct a general personal and professional background check.

* I acknowledge and understand that the result of any personal or professional background check will be kept confidential by ASA and that I will be entitled to address any negative information reported with such background check.

* I agree that it is in the full discretion of ASA to accept or reject my application for membership and that the fee of $30 for the background check fee is non-refundable.

* I understand that I may unilaterally withdraw, or be required to withdraw, from ASA membership or participation at any time, and that any notice of withdrawal by me or by the ASA will be made in writing.

* Upon acceptance as a Professional Member of ASA, I will abide by all rules, policies and procedures promulgated by the governing body of ASA.

* Upon acceptance by ASA, I will participate in ASA at the Professional Member level. I acknowledge that the fee for the remainder of 2009 is $225, and that the 2010 annual fee is $900 per year (payable at the rate of $225 per quarter).

* With the submission of this application I enclose two checks payable to Asheville Strategic Alliance as follows: (1) $30 for background check and (2) $225 for pro-rated 2009 membership fee.

___________________________________________ Signed
(Signature of Applicant)

___________________________________________ Printed
(Name of Applicant)

___________________________________________ Date


___________________________________________ Sponsor
(Signature of Sponsor - ASA Founding Member)

___________________________________________ Date

SPECIAL NOTE: Please mail your completed application and two checks payable to:
Asheville Strategic Alliance
149 South Lexington Avenue
Asheville, NC 28801

Thank you. We appreciate your interest in the Asheville Strategic Alliance and will be in touch with you soon.

- The ASA/FWF Founding Members
David Kanis - Lending & Credit
Mary Hart, JD - Legal Services
Anthony Mitchell - Insurance Services
Mike Sowinski, CPA - Accounting & Taxes
Doug English, CFP - Financial Planning & Investing
Reeta Wolfsohn, CMSW – Financial Social Work & Counseling

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