5 MOUNTAIN®

Family Business Peer Group Application

NOTE: All information is treated confidentially and will not be distributed without permission to any person or organization outside our Center.

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Today's Date

Name

First

Last

Current Position/Title

Company Name

Business Phone

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Send Invoice to the attention (include email):

Cell Phone

Birthdate

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Shareholder(s) Please Employed

Spouse's Name

Children's Name(s) and Birth Year(s)

Referred By:

5 MOUNTAIN® Information

What are your hopes with joining our Peer Group?

Year Business Founded

Board Members – Please List Name(s)

Shareholder(s) – Please List Name(s)

Family Members Employed by Business

Number of Employees

Annual Sales $

Website

Accountant

Financial Planner

Attorney

Other Advisors

Application Submission

Please consider this my formal application for membership in the 5 MOUNTAIN® Family Business Peer Group. Should my application for membership be accepted, I understand my commitments as follows:
1. Honor Confidentiality Covenant and Code of Conduct.
2. Regular participation in monthly Peer Group meetings and Executive Coaching Sessions.
3. Host meetings on a rotating basis; provide light lunch, company introduction and tour.
4. Maintain Family Business Forum Membership and participate in Forums.
5. Pay quarterly dues within net 15 days of invoice date.
6. Thirty-day (30) written notice of cancellation.

Signature

Clear Signature

Please submit your check to:

Delaware Valley Family Business Center
340 North Main Street
Telford, PA 18969

Phone: (215) 723-8413