Membership Application
BUSINESS INFORMATION
Business Name:
Main Business Category:
Main Business Sub Category:
2nd Business Category:
2nd Business Sub Category:
3rd Business Category:
3rd Business Sub Category:
Business Description:
Street Address:
City:
State:
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:

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:
Credit Card Billing: Credit Card Number:
Name On Card
Security Code
Valid Through
Credit Card Address 1
Credit Card Address 2
Credit Card City
Credit Card State
Credit Card Zip
Credit Card Phone Number
Credit Card Country
Credit Card Email Address
Please click submit only one time.  The transaction may take several seconds.