Membership Application

Organization Information (to be displayed online)
Organization Name *
Address 1 *
Address 2
City *
State *
Zip *
Phone *
Fax
Website
Email *
Business Description *
Main Contact
First Name *
Last Name *
Address 1 *
Address 2
City *
State *
Zip *
Title
Phone *
Email *
Additional Contacts
Billing Address (if different)
Street
City
State
Zip
Mailing Address (if different)
Street
City
State
Zip
Additional Information
Referred by
How did you hear about us? *
What is your reason for joining?
Membership Investment
Membership Type: *
Primary Directory Category *
Additional Directory Categories
**Hold CTRL on your keyboard to select multiple categories**
Number of Full Time Employees:  
Number of Part Time Employees:  

Do not include contractors 1099 personnel when counting full-time or part-time employees. "Umbrella memberships" are available to independent contractors of Chamber members at $75.00 each.
Additional of Location Listings:
($200/add. location. Only count locations to get a listing): 		 
   
$ 
$ 
Total: $ 

The contents of this box are for testing purposes. This box will be removed when the form goes live.


Full-Time Employees
Part-Time Employees
Hotel/Motel Rooms
Restaurant Seats
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
AdditionalCategories
Additional Categories Cost
NumberOfAdditionalCategories
additionalItem1Cost
Annual Dues (charged to card)
Tax (charged to card)
Fee (charged to card)
tempValueForDropDown1
Number of Rooms (Accommodations):  
Number of Seats (Restaurants):  
Number of Associates (Realtors, Attorneys):  
Millions in Assets (Financial Institutions):  
$ 
Enhanced Membership ($50):
*
Credit Card Information
Credit Card Type *
Credit Card Number * 
Name On Card
Security Code
Valid Through
Credit Card Address 1
Credit Card City
Credit Card State
Credit Card Zip
Credit Card Phone Number
Credit Card Email Address
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