Membership Application | Ankeny Area Chamber of Commerce

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:

Please click submit only one time. The transaction may take several seconds.