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Membership Application

Employer Information
*Full Name:
*Address:
*City:
*State:
*Zip:
*Phone Number:
*Cell Number:
*E-mail:
Company Information
*Work Name:
*Address:
*City:
*State:
*Zip:
*Phone Number:
*Fax Number:
	Yes, Please include me in the membership directory
	Yes, Please include my e-mail address in the membership directory
Please select industry type
	Service
	Retail
	Manufacturing
	Wholesale
	Warehousing
	Professional Services
	Non-Profit
	Construction
Membership Class
	Individual Fees Student..........................$30 Senior Citizen..................$30 Individual Associate..........$50 Member
	Business/Corporation Fees 01-10 Employees.............$100 11-20 Employees.............$150 21-50 Employees.............$275 50+ Employees................$500 Non-Profit/Goverment.......$100
*Membership Classification:
*Name of Recruiter:
*Date:
*Pd/Invoiced:
*Amount:
*Check Number:
Help our chamber grow by referring a potential member:
*Contact Name:
*Phone Number:
Membership Class
You must type your name in the box below prior to registration. Please click the appropriate button at the bottom of this page to make this form valid or to cancel.
*Name:
*Date:
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