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<h2 style=”text-align: center;”>Membership Application Form</h2>
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<input type=’text’ style=’display:none;’ name=’returnURL’ value=’http&#x3a;&#x2f;&#x2f;www.craniumconnect.com&#x2f;thank-you’ />
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<style>
tr , td {
padding:6px;
border-spacing:0px;
border-width:0px;
}
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<table style=’width:100%;background-color:white;color:black’>

<tr><td colspan=’2′ style=’text-align:left;color:black;font-family:Arial;font-size:14px;’><strong></strong></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Prefix<span style=’color:red;’>*</span></td><td style=’width:250px;’>
<select style=’width:250px;’ name=’Salutation’>
<option value=’-None-‘>-None-</option>
<option value=’Mr.’>Mr.</option>
<option value=’Mrs.’>Mrs.</option>
</select></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>First Name<span style=’color:red;’>*</span></td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’40’ name=’First Name’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Last Name<span style=’color:red;’>*</span></td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’80’ name=’Last Name’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Company<span style=’color:red;’>*</span></td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’100′ name=’Company’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Title<span style=’color:red;’>*</span></td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’100′ name=’Designation’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Email<span style=’color:red;’>*</span></td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’100′ name=’Email’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Phone<span style=’color:red;’>*</span></td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’30’ name=’Phone’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Mobile<span style=’color:red;’>*</span></td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’30’ name=’Mobile’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Website</td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’255′ name=’Website’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Industry<span style=’color:red;’>*</span></td><td style=’width:250px;’>
<select style=’width:250px;’ name=’Industry’>
<option value=’-None-‘>-None-</option>
<option value=’Other’>Other</option>
<option value=’Accounting’>Accounting</option>
<option value=’Airlines&#x2f;Aviation’>Airlines&#x2f;Aviation</option>
<option value=’Alternative&#x20;Dispute&#x20;Resolution’>Alternative Dispute Resolution</option>
<option value=’Alternative&#x20;Medicine’>Alternative Medicine</option>
<option value=’Animation’>Animation</option>
<option value=’Apparel&#x20;&amp;&#x20;Fashion’>Apparel &amp; Fashion</option>
<option value=’Architecture&#x20;&amp;&#x20;Planning’>Architecture &amp; Planning</option>
<option value=’Arts&#x20;&amp;&#x20;Crafts’>Arts &amp; Crafts</option>
<option value=’Automotive’>Automotive</option>
<option value=’Aviation&#x20;&amp;&#x20;Aerospace’>Aviation &amp; Aerospace</option>
<option value=’Banking’>Banking</option>
<option value=’Biotechnology’>Biotechnology</option>
<option value=’Broadcast&#x20;Media’>Broadcast Media</option>
<option value=’Building&#x20;Materials’>Building Materials</option>
<option value=’Business&#x20;Supplies&#x20;&amp;&#x20;Equipment’>Business Supplies &amp; Equipment</option>
<option value=’Capital&#x20;Markets’>Capital Markets</option>
<option value=’Chemicals’>Chemicals</option>
<option value=’Civic&#x20;&amp;&#x20;Social&#x20;Organization’>Civic &amp; Social Organization</option>
<option value=’Civil&#x20;Engineering’>Civil Engineering</option>
<option value=’Commercial&#x20;Real&#x20;Estate’>Commercial Real Estate</option>
<option value=’Computer&#x20;&amp;&#x20;Network&#x20;Security’>Computer &amp; Network Security</option>
<option value=’Computer&#x20;Games’>Computer Games</option>
<option value=’Computer&#x20;Hardware’>Computer Hardware</option>
<option value=’Computer&#x20;Networking’>Computer Networking</option>
<option value=’Computer&#x20;Software’>Computer Software</option>
<option value=’Construction’>Construction</option>
<option value=’Consumer&#x20;Electronics’>Consumer Electronics</option>
<option value=’Consumer&#x20;Goods’>Consumer Goods</option>
<option value=’Consumer&#x20;Services’>Consumer Services</option>
<option value=’Cosmetics’>Cosmetics</option>
<option value=’Dairy’>Dairy</option>
<option value=’Defense&#x20;&amp;&#x20;Space’>Defense &amp; Space</option>
<option value=’Design’>Design</option>
<option value=’Education&#x20;Management’>Education Management</option>
<option value=’E-learning’>E-learning</option>
<option value=’Electrical&#x20;&amp;&#x20;Electronic&#x20;Manufacturing’>Electrical &amp; Electronic Manufacturing</option>
<option value=’Entertainment’>Entertainment</option>
<option value=’Environmental&#x20;Services’>Environmental Services</option>
<option value=’Events&#x20;Services’>Events Services</option>
<option value=’Executive&#x20;Office’>Executive Office</option>
<option value=’Facilities&#x20;Services’>Facilities Services</option>
<option value=’Farming’>Farming</option>
<option value=’Financial&#x20;Services’>Financial Services</option>
<option value=’Fine&#x20;Art’>Fine Art</option>
<option value=’Fishery’>Fishery</option>
<option value=’Food&#x20;&amp;&#x20;Beverages’>Food &amp; Beverages</option>
<option value=’Food&#x20;Production’>Food Production</option>
<option value=’Fundraising’>Fundraising</option>
<option value=’Furniture’>Furniture</option>
<option value=’Gambling&#x20;&amp;&#x20;Casinos’>Gambling &amp; Casinos</option>
<option value=’Glass,&#x20;Ceramics&#x20;&amp;&#x20;Concrete’>Glass, Ceramics &amp; Concrete</option>
<option value=’Government&#x20;Administration’>Government Administration</option>
<option value=’Government&#x20;Relations’>Government Relations</option>
<option value=’Graphic&#x20;Design’>Graphic Design</option>
<option value=’Health,&#x20;Wellness&#x20;&amp;&#x20;Fitness’>Health, Wellness &amp; Fitness</option>
<option value=’Higher&#x20;Education’>Higher Education</option>
<option value=’Hospital&#x20;&amp;&#x20;Health&#x20;Care’>Hospital &amp; Health Care</option>
<option value=’Hospitality’>Hospitality</option>
<option value=’Human&#x20;Resources’>Human Resources</option>
<option value=’Import&#x20;&amp;&#x20;Export’>Import &amp; Export</option>
<option value=’Individual&#x20;&amp;&#x20;Family&#x20;Services’>Individual &amp; Family Services</option>
<option value=’Industrial&#x20;Automation’>Industrial Automation</option>
<option value=’Information&#x20;Services’>Information Services</option>
<option value=’Information&#x20;Technology&#x20;&amp;&#x20;Services’>Information Technology &amp; Services</option>
<option value=’Insurance’>Insurance</option>
<option value=’International&#x20;Affairs’>International Affairs</option>
<option value=’International&#x20;Trade&#x20;&amp;&#x20;Development’>International Trade &amp; Development</option>
<option value=’Internet’>Internet</option>
<option value=’Investment&#x20;Banking&#x2f;Venture’>Investment Banking&#x2f;Venture</option>
<option value=’Investment&#x20;Management’>Investment Management</option>
<option value=’Judiciary’>Judiciary</option>
<option value=’Law&#x20;Enforcement’>Law Enforcement</option>
<option value=’Law&#x20;Practice’>Law Practice</option>
<option value=’Legal&#x20;Services’>Legal Services</option>
<option value=’Legislative&#x20;Office’>Legislative Office</option>
<option value=’Leisure&#x20;&amp;&#x20;Travel’>Leisure &amp; Travel</option>
<option value=’Libraries’>Libraries</option>
<option value=’Logistics&#x20;&amp;&#x20;Supply&#x20;Chain’>Logistics &amp; Supply Chain</option>
<option value=’Luxury&#x20;Goods&#x20;&amp;&#x20;Jewelry’>Luxury Goods &amp; Jewelry</option>
<option value=’Machinery’>Machinery</option>
<option value=’Management&#x20;Consulting’>Management Consulting</option>
<option value=’Maritime’>Maritime</option>
<option value=’Marketing&#x20;&amp;&#x20;Advertising’>Marketing &amp; Advertising</option>
<option value=’Market&#x20;Research’>Market Research</option>
<option value=’Mechanical&#x20;or&#x20;Industrial&#x20;Engineering’>Mechanical or Industrial Engineering</option>
<option value=’Media&#x20;Production’>Media Production</option>
<option value=’Medical&#x20;Device’>Medical Device</option>
<option value=’Medical&#x20;Practice’>Medical Practice</option>
<option value=’Mental&#x20;Health&#x20;Care’>Mental Health Care</option>
<option value=’Military’>Military</option>
<option value=’Mining&#x20;&amp;&#x20;Metals’>Mining &amp; Metals</option>
<option value=’Motion&#x20;Pictures&#x20;&amp;&#x20;Film’>Motion Pictures &amp; Film</option>
<option value=’Museums&#x20;&amp;&#x20;Institutions’>Museums &amp; Institutions</option>
<option value=’Music’>Music</option>
<option value=’Nanotechnology’>Nanotechnology</option>
<option value=’Newspapers’>Newspapers</option>
<option value=’Nonprofit&#x20;Organization&#x20;Management’>Nonprofit Organization Management</option>
<option value=’Oil&#x20;&amp;&#x20;Energy’>Oil &amp; Energy</option>
<option value=’Online&#x20;Publishing’>Online Publishing</option>
<option value=’Outsourcing&#x2f;Offshoring’>Outsourcing&#x2f;Offshoring</option>
<option value=’Package&#x2f;Freight&#x20;Delivery’>Package&#x2f;Freight Delivery</option>
<option value=’Packaging&#x20;&amp;&#x20;Containers’>Packaging &amp; Containers</option>
<option value=’Paper&#x20;&amp;&#x20;Forest&#x20;Products’>Paper &amp; Forest Products</option>
<option value=’Performing&#x20;Arts’>Performing Arts</option>
<option value=’Pharmaceuticals’>Pharmaceuticals</option>
<option value=’Philanthropy’>Philanthropy</option>
<option value=’Photography’>Photography</option>
<option value=’Plastics’>Plastics</option>
<option value=’Political&#x20;Organization’>Political Organization</option>
<option value=’Primary&#x2f;Secondary&#x20;Education’>Primary&#x2f;Secondary Education</option>
<option value=’Printing’>Printing</option>
<option value=’Professional&#x20;Training’>Professional Training</option>
<option value=’Program&#x20;Development’>Program Development</option>
<option value=’Public&#x20;Policy’>Public Policy</option>
<option value=’Public&#x20;Relations’>Public Relations</option>
<option value=’Public&#x20;Safety’>Public Safety</option>
<option value=’Publishing’>Publishing</option>
<option value=’Railroad&#x20;Manufacture’>Railroad Manufacture</option>
<option value=’Ranching’>Ranching</option>
<option value=’Real&#x20;Estate’>Real Estate</option>
<option value=’Recreational’>Recreational</option>
<option value=’Facilities&#x20;&amp;&#x20;Services’>Facilities &amp; Services</option>
<option value=’Religious&#x20;Institutions’>Religious Institutions</option>
<option value=’Renewables&#x20;&amp;&#x20;Environment’>Renewables &amp; Environment</option>
<option value=’Research’>Research</option>
<option value=’Restaurants’>Restaurants</option>
<option value=’Retail’>Retail</option>
<option value=’Security&#x20;&amp;&#x20;Investigations’>Security &amp; Investigations</option>
<option value=’Semiconductors’>Semiconductors</option>
<option value=’Shipbuilding’>Shipbuilding</option>
<option value=’Sporting&#x20;Goods’>Sporting Goods</option>
<option value=’Sports’>Sports</option>
<option value=’Staffing&#x20;&amp;&#x20;Recruiting’>Staffing &amp; Recruiting</option>
<option value=’Supermarkets’>Supermarkets</option>
<option value=’Telecommunications’>Telecommunications</option>
<option value=’Textiles’>Textiles</option>
<option value=’Think&#x20;Tanks’>Think Tanks</option>
<option value=’Tobacco’>Tobacco</option>
<option value=’Translation&#x20;&amp;&#x20;Localization’>Translation &amp; Localization</option>
<option value=’Transportation&#x2f;Trucking&#x2f;Railroad’>Transportation&#x2f;Trucking&#x2f;Railroad</option>
<option value=’Utilities’>Utilities</option>
<option value=’Venture&#x20;Capital’>Venture Capital</option>
<option value=’Veterinary’>Veterinary</option>
<option value=’Warehousing’>Warehousing</option>
<option value=’Wholesale’>Wholesale</option>
<option value=’Wine&#x20;&amp;&#x20;Spirits’>Wine &amp; Spirits</option>
<option value=’Wireless’>Wireless</option>
<option value=’Writing&#x20;&amp;&#x20;Editing’>Writing &amp; Editing</option>
</select></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Annual Revenue</td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’16’ name=’Annual Revenue’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>No. of Employees</td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’9′ name=’No of Employees’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Street</td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’250′ name=’Street’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Zip Code</td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’30’ name=’Zip Code’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>City</td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’100′ name=’City’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Country</td><td style=’width:250px;’ ><input type=’text’ style=’width:250px;’ maxlength=’100′ name=’Country’ /></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Choose your interests<span style=’color:red;’>*</span></td><td style=’width:250px;’>
<select style=’width:250px;’ name=’LEADCF4′ multiple>
<option value=’Blockchain’>Blockchain</option>
<option value=’AI’>AI</option>
<option value=’Migrations&#x20;and&#x20;upgrades’>Migrations and upgrades</option>
<option value=’Digital&#x20;Transformation’>Digital Transformation</option>
<option value=’Digital&#x20;Engagement&#x20;Model’>Digital Engagement Model</option>
</select></td></tr>

<tr><td style=’nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;’>Please provide other interests </td><td> <textarea name=’LEADCF5′ maxlength=’2000′ style=’width:250px;’>&nbsp;</textarea></td></tr>

<tr><td colspan=’2′ style=’text-align:center; padding-top:15px;font-size:12px;’>
<input style=’font-size:12px;color:white’ type=’submit’ value=’Submit’ />
<input type=’reset’ style=’font-size:12px;color:white’ value=’Reset’ />
</td>
</tr>
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var fldLangVal=new Array(‘Last Name’,’First Name’,’Prefix’,’Company’,’Email’,’Phone’,’Title’,’Mobile’,’Industry’,’Choose your interests’);
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} else if(fieldObj.type ==’checkbox’){
if(fieldObj.checked == false){
alert(‘Please accept ‘+fldLangVal[i]);
fieldObj.focus();
return false;
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}
try {
if(fieldObj.name == ‘Last Name’) {
name = fieldObj.value;
}
} catch (e) {}
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}
trackVisitor();
}
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