ChamberMaster Template

Member Application

We would love to have you and your business as part of the chamber.

Business Information

Company Name: *

Leave Blank:

Phone: *

Website: *

Email: *

Business Description (200 char max):

Directory Category: *

Employees: *

Full-time Part-time

Business Keywords (enter a space between words):

Comments / Questions:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Social Networking:

LinkedIn Facebook

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Level One Annual Membership (1-5 Full Time Employees) : $175.00
Level Two Annual Membership (6-10 Full Time Employees) : $250.00
Level Three Annual Membership (11-20 Full Time Employees) : $330.00
Level Four Annual Membership (21-40 Full Time Employees) : $400.00
Level Five Annual Membership (41-100 Full Time Employees) : $550.00
Corporate Annual Membership (100+ Full Time Employees) : $1,210.00

Payment Option:

Bill me Charge my credit or debit card

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ChamberMaster Template

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ChamberMaster Template

Member Application

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