Corporate Membership & Engagement Application

Corporate Membership & Engagement Application
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Website Address
Company Description
Primary Contact*

First NameLast Name
Primary Contact's Title*
Primary Contact's Phone Number*
Please enter a valid phone number.
Primary Contact's Email Address*
example@example.com
Secondary Contact

First NameLast Name
Secondary Contact's Title
Secondary Contact's Phone Number
Please enter a valid phone number.
Secondary Contact's Email Address
example@example.com
C-Suite Representative Name

First NameLast Name
C-Suite Representative's Title
C-Suite Representative's Phone Number
Please enter a valid phone number.
C-Suite Representative's Email Address
example@example.com
NOTE: This individual will be extended invitations to participate in ChicagoMSDC exclusive C-Suite summits and forums.
How did you hear about ChicagoMSDC?*
Year Supplier Diversity Program Established*
Number of Employees*
Please select 1-3 key areas of focus with ChicagoMSDC

Access to ChicagoMSDC's database of qualified suppliersDiversity education and trainingGrowth of our corporate diversity program(s)Support of ChicagoMSDC's programs and servicesMeet our business obligations and requirementsNetwork with local minority businessesNetwork with other corporationsNetwork with government agenciesBecome a part of the NationalMSDC networkOther
CORPORATE REFERRAL - If you know of another corporation that could benefit from membership with ChicagoMSDC please provide their information below:
Company Name, Contact Name and Title, Email Address and Phone Number.
Company Name
Point of Contact

First NameLast Name
Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Are you available as a reference?

YesNo
Method of Payment*

Invoiced to Pay by CheckCredit Card
ChicagoMSDC Annual Membership Fee Structure*

Non-Profit Organization (1,001 to 5,000 Employees - $2,000.00 Fee)For-Profit Organization (1 to 500 Employees - $5,000.00 Fee)For-Profit Organization (500 to 3,000 Employees - $5,700.00 Fee)For-Profit Organization (3,000 to 10,000 Employees - $6,100.00 Fee)For-Profit Organization (10,000 or More - $6,600.00)

ChicagoMSDC Annual Membership Fee Structure*

Non-Profit OrganizationEnter description

$2,000.00

For-Profit Organization Size

1- 500 Employees

$5,000.00

500 - 3,000 Employees

$5,700.00

3,000 - 10,000 Employees

$6,100.00

10,000 or More Employees

$6,600.00

Total

$0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: