Membership Application Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you interested in joining a committee? Please indicate the committee your are interested in supporting
Emancipation Avenue Main Street
Resilient Entrepreneurship Program/Economic Develo
Community-led Food System
Community Volunteer
Third Ward is Home Civic Club
Other
Business and Organizations
Business Name/ Organization
*
Business Email
*
example@example.com
Website
*
Business Type
Please Select
Community Organization
Church
Restaurant
Retail
Health and Wellness
Bar
Services
Operations
Please Select
Operates Online Only
Operates by Appointment Only
Has Storefront Hours
Please Select all that Apply
Black Owned
Woman Owned
Veteran Owned
LGBTQ Owned
Nonprofit
Worker Owned (Co-Operative)
Other Ownership Structure
Number of Staff
0-2
2-5
5-10
10-20
Other
Membership Type:
*
Protect: Membership - Individual - $50
Preserve: Business Membership - $100
Preserve: Community Legacy - $500
Revitalization Partner -Community Impact - $1,000
Revitalization Partner - Economic Impact - $5,000
Payments accepted via Paypal
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: