CGCBB New Member Registration

1
Name* This field is required.
First Name
Last Name
2
Business/Organization Name* This field is required.
(*If you do not have a business yet, enter "Aspiring Business")
3
What type of business/organization are you representing?* This field is required.
Please Select
Please Select
For-profit Business
Non-profit Organization
*Aspiring Entrepreneur
4
What Industry is your organization a part of?* This field is required.
Please Select
Please Select
Agriculture and Farming
Arts and Entertainment
Automotive and Transportation
Beauty and Personal Care
Coaching & Consulting
Construction and Architecture
Education and Training
Energy and Utilities
Environmental and Sustainability
Fashion and Apparel
Financial Services and Banking
Fitness and Wellness
Food and Beverage
Government and Public Sector
Healthcare and Pharmaceuticals
Home and Interior Design
Hospitality and Tourism
Manufacturing and Engineering
Media and Communications
Nonprofit and Social Services
Professional Services (Legal, Consulting, Accounting)
Real Estate and Property Development
Retail and E-commerce
Sports and Recreation
Startups and Entrepreneurship
Technology and Software
I'm not sure yet (Aspiring)
(Select the industry most closely related to your business/organization)
5
Business Email * This field is required.
(*No business email? Enter your personal email.)
6
Personal Email (optional)
7
Business Phone Number* This field is required.
Area Code
Phone Number
8
Personal Phone Number (optional)
Area Code
Phone Number
9
Business Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Please select your COUNTY* This field is required.
Please Select
Please Select
Appling County
Atkinson County
Bacon County
Baker County
Baldwin County
Banks County
Barrow County
Bartow County
Ben Hill County
Berrien County
Bibb County
Bleckley County
Brantley County
Brooks County
Bryan County
Bulloch County
Burke County
Butts County
Calhoun County
Camden County
Candler County
Carroll County
Catoosa County
Charlton County
Chatham County
Chattahoochee County
Chattooga County
Cherokee County
Clarke County
Clay County
Clayton County
Clinch County
Cobb County
Coffee County
Colquitt County
Columbia County
Cook County
Coweta County
Crawford County
Crisp County
Dade County
Dawson County
Decatur County
DeKalb County
Dodge County
Dooly County
Dougherty County
Douglas County
Early County
Echols County
Effingham County
Elbert County
Emanuel County
Evans County
Fannin County
Fayette County
Floyd County
Forsyth County
Franklin County
Fulton County
Gilmer County
Glascock County
Glynn County
Gordon County
Grady County
Greene County
Gwinnett County
Habersham County
Hall County
Hancock County
Haralson County
Harris County
Hart County
Heard County
Henry County
Houston County
Irwin County
Jackson County
Jasper County
Jeff Davis County
Jefferson County
Jenkins County
Johnson County
Jones County
Lamar County
Lanier County
Laurens County
Lee County
Liberty County
Lincoln County
Long County
Lowndes County
Lumpkin County
Macon County
Madison County
Marion County
McDuffie County
McIntosh County
Meriwether County
Miller County
Mitchell County
Monroe County
Montgomery County
Morgan County
Murray County
Muscogee County
Newton County
Oconee County
Oglethorpe County
Paulding County
Peach County
Pickens County
Pierce County
Pike County
Polk County
Pulaski County
Putnam County
Quitman County
Rabun County
Randolph County
Richmond County
Rockdale County
Schley County
Screven County
Seminole County
Spalding County
Stephens County
Stewart County
Sumter County
Talbot County
Taliaferro County
Tattnall County
Taylor County
Telfair County
Terrell County
Thomas County
Tift County
Toombs County
Towns County
Treutlen County
Troup County
Turner County
Twiggs County
Union County
Upson County
Walker County
Walton County
Ware County
Warren County
Washington County
Wayne County
Webster County
Wheeler County
White County
Whitfield County
Wilcox County
Wilkes County
Wilkinson County
Worth County
*I do not live in Georgia
(Select the Georgia County you live in)
11
Business/Organization Website (optional)
12
Business Logo (Optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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13
How long have you been in business?* This field is required.
I'm not in business yet
Less than 1 year
1-3 years
4-7 years
8-10 years
11-15 years
16-20 years
21-25 years
More than 25 years
14
Are you certified or licensed in your field/industry?* This field is required.
Yes
No
Pending Certification
Certification Not Required
15
Have you received any contracts from any of the following: (select all that apply)* This field is required.
Macon-Bibb County
Another County or Municipality
State of Georgia
Another State other than Georgia
Federal Government
No, I have not
16
Where did you hear about The Coalition?
Coalition Member
Social Media
Event
Google
A friend or colleague
Eventbrite
Other
17
Which of these answers most resonates with you? I'm joining the Coalition to:
Find more clients for my business
Network with like-minded people
Grow professionally
Help improve the current state of Black-owned businesses
Help improve the state of the Black Community
18
Let us know your Birthday!* This field is required.
Month
Day
Year
19
What is your gender?* This field is required.
Male
Female
Other
I'd prefer not to answer
20
What is your age?* This field is required.
Younger than 18 years
18-24
25-35
36-40
41-50
51-60
61-75
76+
I'd prefer not to answer
21
Have you served in the military?* This field is required.
Yes
No
22
Please Upload a headshot of yourself.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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23
Affirmation of Expected Conduct* This field is required.
I affirm that as a member of the Central Georgia Coalition of Black Businesses, I agree to uphold the organization's ethos, code of ethics, and professionalism at all times when representing or engaging with the coalition. I understand that failure to adhere to these standards may result in the rescinding of my membership by the Board of Directors.
24
Affirmation of Understanding* This field is required.
I understand that by submitting this application for membership to the Central Georgia Coalition of Black Businesses and making the associated payment, I acknowledge that my membership is subject to approval and acceptance by the Board of Directors. In the event that the Board of Directors decides not to approve and accept my membership, I understand that my payment will be refunded.
25
Signature* This field is required.
Clear
26
Membership Tiers & Associated Investments* This field is required. Emerging Business ANNUAL $150.00 The Emerging Business annual subscription requires a one-time investment of $150 and covers one (1) full year of membership. Emerging Business MONTHLY $11.37 (First payment $25) Emerging Business monthly subscription requires $13.63 set-up fee + first month's investment ($11.37 monthly invest/12 months). Small Business ANNUAL $250.00 The Small Business annual subscription requires a one-time investment of $250 and covers one (1) full year of membership. Small Business MONTHLY $18.19 (First payment $50) Small Business monthly subscription requires $31.81 set-up fee + first month's investment ($18.19 monthly invest/12 months). Business Executive ANNUAL $500.00 The Business Executive annual subscription requires a one-time investment of $500 and covers one (1) full year of membership. Business Executive MONTHLY $31.82 (First payment $150) Business Exec monthly subscription requires $118.18 set-up fee + first month's investment ($31.82 monthly invest/12 months).
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