Member Application

    
        















        

        
        
            
                Business Information
            
            
                
                    
                                Company Name:
            *

                        
                    
                
                
                    
                                Leave Blank:

                        
                    
                
                    
                        
                                    Phone:
            *

                            
                        
                    
                                    
                        
                                    Website:

                            
                        
                    
                                    
                        
                                    Email:
            *

                            
                        
                    
                                                    
                        
                                    Directory Category:

                            
                        
                    
                                    
                                Employees:
            *

                        
                            
                                Full-time
                                
                            
                            
                                Part-time
                                
                            
                            
                        
                    
                                                    
                        
                                    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:
            *

                            
                            
                        
                    
                
                    
            
                
                    Primary Contact Information
                
                
                    
                        
                                    First Name:
            *

                            
                        
                    
                    
                        
                                    Last Name:
            *

                            
                        
                    
                        
                            
                                        Title:

                                
                            
                        
                                            
                            
                                        Phone:
            *

                                
                            
                        
                                            
                            
                                        Cell Phone:

                                
                            
                        
                                            
                            
                                        Fax:

                                
                            
                        
                                            
                            
                                        Email:
            *

                                
                            
                        
                                            
                            Contact Preference:
                            
                                
                                    
                                    Email
                                
                                
                                    
                                    Phone
                                
                            
                        
                                            
                            
                                        Login:
            *

                                
                            
                        
                        
                            
                                        Password:
            *

                                
                            
                        
                        
                            
                                
                            
                            
                        
                                                                
                            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
                                
                            
                        
                                            
                            
                                        Login:
            *

                                
                            
                        
                        
                            
                                        Password:
            *

                                
                            
                        
                        
                            
                                
                            
                            
                        
                                                                
                            Address
                                
                                    
                                        
                                        Same as Member Address
                                    
                                
                            
                                
                                            Line 1:
            *

                                    
                                
                            
                            
                                
                                    Line 2
                                    
                                
                            
                            
                                
                                            City:
            *

                                    
                                
                            
                            
                                
                                            State:
            *

                                    
                                
                            
                            
                                
                                            Postal Code:
            *

                                    
                                
                            
                            
                                
                                            Country:
            *

                                    
                                    
                                
                            
                        
                
            
        
            
                Membership Options
            
            
                    
                                Membership Package:
            *

                        
                                
                                    
                                    
                                        Individual:
                                        
$100.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Home-Based:
                                        
$150.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Churches & Civic Organizations:
                                        
$175.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Business 1 to 10 employees (1 Designee):
                                        
$275.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Business 11 to 50 employees (2 Designee):
                                        
$375.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Business 51 to 100 employees (3 Designee):
                                        
$500.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Business 101 to 250 employees (4 Designee):
                                        
$600.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Business 251+ employees (5 Designee):
                                        
$850.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Hotels:
                                        
                                                    Please contact us to determine the fee.
                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Government:
                                        
$350.00                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Hospitals:
                                        
                                        

                                        
                                    
                                
                                
                                    
                                    
                                        Banks and Credit Unions:
                                        
                                                    Please contact us to determine the fee.
                                        

                                        
                                    
                                
                                                    
                    
                                                                    
                        Payment Option:
                        
                                
                                    
                                    Bill me
                                
                                                    
                    
            
        
        
            
                
                    
                
            
        
        
            
                
                    Please scroll down to view the entire policy and then click Accept.

                    
                    

                    

                    
                        
                        Decline
                    
                
            
            
                
                I have read and accept the privacy policy of Greater Minden Chamber of Commerce. I grant Greater Minden Chamber of Commerce permission to contact me regarding my account, news, updates, and offers.
            
            
                
                    Please read and accept the privacy policy before continuing.
                
            
        
        
            
                
                Print Application
            
        
    




        Business Directory  
                                    Contact Us
                Join The Chamber