Membership Application BUSINESS INFORMATION Business Name: Main Business Category: *None Advertising & Media Agriculture & Fishing & Forestry Arts Culture & Entertainment Automotive & Aviation & Marine Business & Professional Services Communications Computers & IT & Technology Employment & Staffing Family Community & Non-Profit Finance & Insurance Government & Education Health Care Home & Garden Industrial & Manufacturing Lodging Travel & Tourism Personal Services & Care Pets & Veterinary Public Utilities & Environment Real Estate & Construction Religious Organizations Restaurants Food & Beverages Shopping & Specialty Retail Sports & Recreation Other Main Business Sub Category: *None Advertising Agribusiness Air Service Ambassador Animal Archival Products Audio-Visual Automotive Awards AYP Brewery - Winery Business Products Business Services Children Cleaning-Maintenance Clock Repair Communications Computer Construction Contractor Dance-Gymnastics-Cheerleading Data Day Care Delivery Dental Design Services Distributors Drug & Alcohol Testing Education Employment Entertainment-Recreation Environmental Events & Party Supplies Facilities Finance Fitness Food-Beverage Freelance Funeral Services Government Handyman Health & Beauty Health Care - Health Care Providers Hotel-Motel Human Services Independent Consultant Individual Membership Industrial Insurance-Finance International Internet Provider Landscape Language Translator Lawn Maintenance Legal Services Libraries-Museums Locksmith Mailing-Shipping Manufacturing Marketing Mental Health Military Moving Music Organizations Parks & Campgrounds Personal Assistance Photography Political Printing Private Clubs Public Speaker Publications Real Estate Religious Affiliations Repair Restaurants Retail-Shops-Stores Scrap Yard Security-Safety Senior Signage Small Business Assistance Snow Removal Storage Technology Transportation Travel Trucking Utilities Welcome Services Wholesale 2nd Business Category: *None Advertising & Media Agriculture & Fishing & Forestry Arts Culture & Entertainment Automotive & Aviation & Marine Business & Professional Services Communications Computers & IT & Technology Employment & Staffing Family Community & Non-Profit Finance & Insurance Government & Education Health Care Home & Garden Industrial & Manufacturing Lodging Travel & Tourism Personal Services & Care Pets & Veterinary Public Utilities & Environment Real Estate & Construction Religious Organizations Restaurants Food & Beverages Shopping & Specialty Retail Sports & Recreation Other 2nd Business Sub Category: *None Advertising Agribusiness Air Service Ambassador Animal Archival Products Audio-Visual Automotive Awards AYP Brewery - Winery Business Products Business Services Children Cleaning-Maintenance Clock Repair Communications Computer Construction Contractor Dance-Gymnastics-Cheerleading Data Day Care Delivery Dental Design Services Distributors Drug & Alcohol Testing Education Employment Entertainment-Recreation Environmental Events & Party Supplies Facilities Finance Fitness Food-Beverage Freelance Funeral Services Government Handyman Health & Beauty Health Care - Health Care Providers Hotel-Motel Human Services Independent Consultant Individual Membership Industrial Insurance-Finance International Internet Provider Landscape Language Translator Lawn Maintenance Legal Services Libraries-Museums Locksmith Mailing-Shipping Manufacturing Marketing Mental Health Military Moving Music Organizations Parks & Campgrounds Personal Assistance Photography Political Printing Private Clubs Public Speaker Publications Real Estate Religious Affiliations Repair Restaurants Retail-Shops-Stores Scrap Yard Security-Safety Senior Signage Small Business Assistance Snow Removal Storage Technology Transportation Travel Trucking Utilities Welcome Services Wholesale 3rd Business Category: *None Advertising & Media Agriculture & Fishing & Forestry Arts Culture & Entertainment Automotive & Aviation & Marine Business & Professional Services Communications Computers & IT & Technology Employment & Staffing Family Community & Non-Profit Finance & Insurance Government & Education Health Care Home & Garden Industrial & Manufacturing Lodging Travel & Tourism Personal Services & Care Pets & Veterinary Public Utilities & Environment Real Estate & Construction Religious Organizations Restaurants Food & Beverages Shopping & Specialty Retail Sports & Recreation Other 3rd Business Sub Category: *None Advertising Agribusiness Air Service Ambassador Animal Archival Products Audio-Visual Automotive Awards AYP Brewery - Winery Business Products Business Services Children Cleaning-Maintenance Clock Repair Communications Computer Construction Contractor Dance-Gymnastics-Cheerleading Data Day Care Delivery Dental Design Services Distributors Drug & Alcohol Testing Education Employment Entertainment-Recreation Environmental Events & Party Supplies Facilities Finance Fitness Food-Beverage Freelance Funeral Services Government Handyman Health & Beauty Health Care - Health Care Providers Hotel-Motel Human Services Independent Consultant Individual Membership Industrial Insurance-Finance International Internet Provider Landscape Language Translator Lawn Maintenance Legal Services Libraries-Museums Locksmith Mailing-Shipping Manufacturing Marketing Mental Health Military Moving Music Organizations Parks & Campgrounds Personal Assistance Photography Political Printing Private Clubs Public Speaker Publications Real Estate Religious Affiliations Repair Restaurants Retail-Shops-Stores Scrap Yard Security-Safety Senior Signage Small Business Assistance Snow Removal Storage Technology Transportation Travel Trucking Utilities Welcome Services Wholesale Business Description: Street Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zipcode: Phone: Fax: Email: Website: Number of Full-Time Employees: Number of Part-Time Employees: Date Established: BUSINESS CONTACT INFORMATION Main Contact Information (only one main contact will be published with the on-line and print directories) First Name: Last Name: Job Title: Phone: Email: Fax: Additional Representative (to receive email) First Name: Last Name: Job Title: Email: Additional Representative (to receive email) First Name: Last Name: Job Title: Email: MEMBERSHIP COSTS All applications require a $30 fee which is not included in the base rate below, it will be added to your grand total. Base Rate: Premier Membership - $5500 1 -5 Employees - $320 6 - 20 Employees - $350 21 - 50 Employees - $425 51 - 100 Employees - $550 101 - 200 Employees - $775 201 - 300 Employees - $1350 301 - 400 Employees - $2275 400+ Employees - $3200 Professional Membership - (See Dues Schedule) Civic Organizations & Associations - $160 Individual - $110 Hotels/Motels - $550 Financial Institutions (See Dues Schedule) Other - $320 Additional fees apply based on your membership type. Please enter the amount calculated for your business type. Full Time Equivalent Calculation:Dues Schedule Additional Calculated Fee:Dues Schedule Administrative Charge: Charge: Total Payment: How did you hear about the Chamber? (check all that apply) Newspaper: Chamber Member: Internet: Previously a Member: Other: Please List Referral Name: What reason(s) are you joining the Chamber? (Check all that apply) Marketing: Website: Legislative Actions: Professional Growth: Networking: Keep Informed on Local Issues: Committees: Education: Benefits/Discussion: Publications: Events: Other: BILLING INFORMATION Credit Card Type: Mastercard Visa Discover Amex Credit Card Billing: Credit Card Number: Name On Card Security Code Valid Through 01 02 03 04 05 06 07 08 09 10 11 12 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Use Address Above Credit Card Address 1 Credit Card Address 2 Credit Card City Credit Card State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Credit Card Zip Credit Card Phone Number Credit Card Country Credit Card Email Address Please click submit only one time. 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