Member Application

Business Information

Company Name: *

Leave Blank:

Phone: *

Website: *

Email: *

Business Description (200 char max): *

Directory Category: *

Employees: *

Full-time Part-time

Business Keywords (enter a space between words): *

Comments / Questions:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

1-3 Employees: $199.00
4 - 7 Employees: $249.00
8 - 15 Employees: $349.00
16 + Employees: $474.00
School Districts: $474.00
Utility Companies: $474.00
Banks/Credit Unions: $474.00
Non-Profit/Religious Organizations: $149.00
Home-based, Individual, Retired: $99.00
Parent Mmber - Addtl. Name: $75.00
Restaurants: $400.00
$400.00 per year. Please choose from the following options: 1. Payment in full enclosed with application 2. $200.00 with application and $200.00 payable in 6 months. 3. $250.00 payment with application and $150.00 in donations* to Chamber events. 4. $125.00 with application, $125.00 payable in 6 months and $150.00 in donations* to Chamber events.

Payment Option:

Bill me Charge my credit or debit card

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