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Business Information

Company Name: *

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Phone: *

Website: *

Email: *

Business Description (200 char max): *

Directory Category:

Employees:

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Business Keywords (enter a space between words):

Comments / Questions:

What is your reason for joining the Chamber?: *

What is your founding anniversary?: *

Would you like to accept Village Gold?: *

Physical Address

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City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Social Networking:

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Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook Instagram

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:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook Instagram

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Professional Level : $200.00
1-10 employees Professional Level: $250.00
11-49 Employees Silver Level Investor: $500.00
Gold Level Investor: $1,500.00
Platinum Level Investor: $5,000.00

Payment Option:

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Member Application

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