Application

Organization Information (to be displayed online)

Organization Name

Address 1

Address 2

City

State

Zip

Phone

Fax

Website

Main Contact

Copy from Organization-Information

First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

Additional Contacts

Contact 1

First Name

Last Name

Title

Email Address

Contact 2

First Name

Last Name

Title

Email Address

Contact 3

First Name

Last Name

Title

Email Address

Contact 4

First Name

Last Name

Title

Email Address

Contact 5

First Name

Last Name

Title

Email Address

Contact 6

First Name

Last Name

Title

Email Address

Contact 7

First Name

Last Name

Title

Email Address

Contact 8

First Name

Last Name

Title

Email Address

Contact 9

First Name

Last Name

Title

Email Address

Contact 10

First Name

Last Name

Title

Email Address

Add/Remove Contacts

Billing Address (if different)

Address 1

Address 2

City

State

Zip

Mailing Address (if different)

Address 1

Address 2

City

State

Zip

Additional Information

Membership Investment

Membership Type

Primary Directory Category

Additional Directory Categories

Select additional directory categories below by holding the "CTRL" key
Secondary categories may be subject to additional fees

Number of Employees

If your company has more than 500 employees add $50.00 for each additional 20 employees.
Definition of employee for membership purposes: Any person working in or out of your office as a representative, agent, independent contractor, or any other affiliations in which that person represents themselves to be a part of your company.

Municipality ($165 fee)

Annual Membership Investment

Additional Items

Additional Categories Cost

One-Time Application Fee

Tax

Total

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Full-Time Employees

Part-Time Employees

Hotel/Motel Rooms

Restaurant Seats

Additional Associates

Additional Associates Cost

Additional Locations

Additional Locations Cost

Assets

Assets Cost

Additional Categories

Number Of Additional Categories

Additional Categories Cost

Additional Item 1 Cost

Additional Item 2 Cost

Additional Item 3 Cost

Additional Item 4 Cost

Additional Item 5 Cost

Additional Item 6 Cost

Additional Item 7 Cost

Additional Item 8 Cost

Additional Item 9 Cost

Additional Item 10 Cost

Annual Dues (charged to card)

Revenue Item

Tax (charged to card)

Fee (charged to card)

Temp Value For DropDown 1

MembershipType

Additional Item 2

Additional Item 3

Additional Item 4

Additional Item 5

Additional Item 6

Additional Item 7

Additional Item 8

Additional Item 9

Additional Item 10

Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Number of Part Time Employees

Number of Rooms

Number of Seats

Number of Associates

Number of Locations

Millions in Assets

Credit Card Information

Copy from Organization Information

Credit Card Type

Mastercard

Visa

Discover

Amex

Credit Card Number

Name on Card	Required
Security Code	Required
Valid Through
Address	Required
City	Required
State
Zip	Required
Phone	Required
Credit Card Email Address

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Please select a membership type before submitting your application.

The Chamber

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