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 Method:
Credit Card Number:    
Exp: /
3-digit Security Code    
Membership is effective upon receipt of payment:
   
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