MEMBERSHIP APPLICATION
Company Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Contact Person's Name:
Title:
Chamber's Official Representative to the Chamber
Phone #:
Fax #:
Email:
Website:
Please describe your company:
Date when business started:
Number of Employees:
Recommended Membership by:
Reasons for joining the Chamber:
Marketing / Contacts
Programs
Benefits and Savings
Support / Civic Duty
Public Policy
Others
Information / Assistance
Annual Membership Dues
Individual Members (voting members) :
$100.00
Organizational Member (1 to 50 Employees):
$250.00
51 to 100 Employees:
$500.00
100+ Employees:
$1,000
PAYMENT INFORMATION
Membership fee charged to card:
Name on Card:
Title:
Card Number:
Card Type:
Visa
MasterCard
Discover
AMEX
Expiration Date:
Initials: