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Become A Member Become a Member of the Institute of Certified Business Counselors

Institute of Certified Business Counselors Membership Application

* = Required Fields

General Information
* Name: Mr. Mrs. Ms. Dr. Other None
* Date Of Birth: Month: Day: Year:
* Gender: Female Male

Business Information
* Firm Name:
* Position/Title:
* Business Address: Street/POB: City:
State: Zip: Country:
* Telephone:
Fax:
Email:
Website:

Residence Information
* Address: Street/POB: City:
State: Zip: Country:
* Telephone:
Fax:
Email:
Spouse's Name:
* Preferred Mailing Address: Business Residence

Business Activities
Activity Number of Years Percent of Time
Accounting
Legal Counsel
Business Brokerage
Loan Facilitation & Packaging
Business Consulting
Machinery & Eqp Valuation
Business Turnarounds
Management Advisory Services
Business Valuation
Mergers & Acquisitions
Financial Planning
Real Estate Leasing & Sales
Intermediary/Finder
Strategic Planning
Investment Banking
Technology Consulting
* Geographic Area Serviced:

Professional Licences

Licenses States Approved
Appraisal:
CPA:
Insurance:
NASD:
Real Estate:
Technology:
Other Licence(s):

Association Memberships
Professional Association Designations Awarded:
* Have you ever been subjected to a disciplinary action by a state licensing body or had any business or professional licenses revoked or suspended? Yes No
If yes please explain:
* Have you ever been declared by a court of competent jurisdiction to have committed an act of negligence, fraud or dishonesty? Yes No
If yes please explain:
* Have you ever been charged or convicted of a felony? Yes No
If yes please explain:
* Are any lawsuits pending against you? Yes No
If yes please explain:

Education
Organization/Publisher Hours Recommend: Yes No
Courses & Seminars attended during the previous 12 months
University or Institution(s). Degree & Year Completed

References

References that can address I-CBC.s inquiry into your integrity, responsibility and expertise.
* Reference One:
Name:
ICBC Member: Yes No
Relationship:
Phone / Email:
* Reference Two:
Name:
ICBC Member: Yes No
Relationship:
Phone / Email:
* Reference Three:
Name:
ICBC Member: Yes No
Relationship:
Phone / Email:

Resume
Attatch Resume

Membership Agreement
I Agree
 I hereby certify that the statements contained herein are correct and if I am accepted into the membership of the Institute of Certified Business Counselors, I agree to abide by its charter, bylaws, and code of ethics. *

Application Fee

$100

 Please be aware that your membership application is not finalized untill we recieve full payment for $100. You can submit payment by Fax: 503-292-8237 or Mail To: 18831 Willamette Drive, West Linn, OR 97068. For questions, feel free to give us a call at (877) 422-2674. *
verification code
* Security Code:

www.i-cbc.net | membership@i-cbc.org
Phone: 877 i-cbc.org (877.422.2674) Fax: 503.635.1340
18831 Willamette Drive, West Linn, OR 97068