Chamber Information

Membership Investment Agreement Form

Business Information

Business Name

Address

City

State

Zip

Telephone

Fax

Web Site Address

E-Mail Address

Name of Business that checks
are drawn on
(if different than above):

Please Describe your Business (25 words or less):

Payment Schedule

Full Time Equivalent Employees:
Calculation: Total payroll hours per week/40 ( includes management )

Annual Dues:

Administrative Charge:

Total Payment:

Payment Schedule:

Payment Schedule Annual
Payment Schedule Semi-Annual

Payment Method:

CheckVisaMastercardDiscover

Credit Card Number:

Exp:

3-digit Security Code

Membership is effective upon receipt of payment:

Payment is enclosedPlease Invoice Me

Additional Information

Primary Business Representative

First Name:

Last Name:

Additional Representatives (please include address, phone number and e-mail address if different )

Name

Address

Phone Number

E-Mail

Name

Address

Phone Number

E-Mail

Name

Address

Phone Number

E-Mail

Business Categories (3 at no charge; 3 additional at $25 each per year):