First Name : * A value is required.
Middle Name :
Last Name : * A value is required.
Nick Name :
Age:
Marital Status:
Sex : * Male Female
Company Name : * A value is required.
Title : * A value is required.
Business Address : * A value is required.
City : * A value is required.
P.O.Box :
Country : *
E-mail : *
Website :
Business Phone, Extension : *
Mobile : *
Business Fax :
Mailing Address : *
I wish to receive mailings at : My Home My Business
My email Address : *
If Any CEO Club Member References :
Occasionally, the media asks us to supply names of CEOs who they could interview and we, as a policy,
do not supply any information whatsoever. Please check one of the following:
No, do not supply Yes, but clear first with me Yes, anytime
Membership Type *
Basic Membership for 1 year AED 18,000 (USD 4,900 ) :
Basic Membership for 2 years AED 30,000 (USD 8,200):
Premium Membership for 5 years AED 50,000 (USD 15,000) :
Elite Membership for 10 years AED 75,000 (USD 20,500) :
VIP Membership for 1 year AED125,000 (USD35,000) :
Total Enclosed : $
Payment Type : *
Credit Card:
PayPal :
By Cheque : Cheque payable to the "CEO CLUBS NETWORKS" mail with application to:
      CEO CLUBS UAE
      P. O. Box 58162
      Dubai, UAE
Information About Applicant’s Business
Please descirbe your business’ products or services: *
What other organizations are you a Member of?
What would your perfect networking location be in the UAE?
How many employees are in your Organization? * 1 /10 10 /50 50/ 100 150 /500 Over /500
Your annual sales volume is: * Less than $1 million $1 to $10 million $10 to $50 million
$50 to $100 million Over $100 million
Are you a director of your Company? Yes No
Is this a family Business? yes No
Type of Business: Manufacturing Distribution Retail Professional Services
Other
Designated alternate (this person will attend when you can’t):
Personal Information (Optional)
Spouse’s Name :
Names and ages of your children :     Age :
    Age :
    Age :
Please describe any special areas of expertise or your hobbies:
All CEO CLUBS membership application form with payment will be process
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