{% extends "memberships/base-wide.html" %} {% load styled_forms %} {% load i18n %} {% load base_filters %} {% block title %}{% endblock %} {% block meta_description %}{% endblock %} {% block meta_keywords %}{% endblock %} {% block meta_canonical_url %}{% endblock %} {% block extra_head %} {{ block.super }} {% endblock %} {% block body %}

{{ app.name }}

{{ app.description|safe|urlize }}

{{ form.non_field_errors }}
{% for field in form %} {% if field.errors %}
{{ field.label_tag }} {{ field.errors }}
{% endif %} {% endfor %}
{% csrf_token %}

All Fields

 
Section 1: User Information
Salutation
 
First Name*
 
Initials
 
Last Name*
 
Display Name
 
Company
 
Title
 
Functional Title
 
Department
 
Address
 
Address 2
 
City
 
State
 
Zip Code
 
Country
 
Address Type
 
Phone
 
Phone 2
 
Work Phone
 
Home Phone
 
Mobile Phone
 
Pager
 
Fax
 
E-mail*
 
E-mail 2
 
Web Site
 
Web Site 2
 
Hide in Search
Yes    No
 
Hide Address
Yes    No
 
Hide Email
Yes    No
 
Hide Phone
Yes    No
 
DOB
{{ form.dob }}  
Gender
 
Spouse
 
User Name
 
Password

confirm password
 
 
Section 2: Membership Information
Corporate Membership ID   
 
Certifications
 
Work Experience
{{ form.work_experience }}
Areas of Expertise {{ form.areas_of_expertise }}
 
Affiliation Member Number   
 
Primary Practice
How long in practice?   
 
License Number
 
Licensed in State
 
Chapter    {{ form.chapter }}
 
Application Complete?   Yes    No
 
Notes
 
Home State
 
Year Left Native Country   
 
Network Sectors
 
Networking
 
Government Worker
Yes    No
 
Government Agency
Industry
{{ form.industry }}  
Region
{{ form.region }}  
Size of Company
Referral Source
 
Referral Source Other   
 
Referral Source Member Name
Referral Source Member Number   
 
 
Section 3: Membership Type
Membership Type*
{{ form.membership_type }}
 
 
Section 4: Payment
Payment Method*
{{ form.payment_method }}
 
Promotion Code
 
 
Section 5: Education History
Enter your Education History
School: Degree:
Major: Graduation Date:
       
School: Degree:
Major: Year Graduated:
       
School: Degree:
Major: Year Graduated:
       
School: Degree:
Major: Year Graduated:
       
 
Section 6: Career History
Enter your Career History

Company Information:
Name:
Description:
       
Position Information:
Title:
Description:
Start Date: End Date:

Company Information:
Name:
Description:
       
Position Information:
Title:
Description:
Start Date: End Date:

{% if request.user.profile.is_superuser %}
 
Section 7: Superuser Only
Application Approved   Yes    No
 
Admin Notes
{{ form.admin_notes }}
 
Status*
 
Status Detail*
 
{% endif %}
 
 
 
 
{% endblock %} {% block extra_body %} {{ block.super }} {% endblock extra_body %}