Chamber Membership Application

Chamber Membership Application
Date

MonthDayYear
Date
Profile Details
Company or Individual Name*
Business Type:
Select One
Main Representative*
Name of contact person to be visible in online membership directory listing.
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email*
example@example.com
Website Address:
http://www.yourwebsite.com
Chamber Membership Subscriptions

Complete Subscription Order Below
*Multiple Ownership-First Business will pay base Membership Dues plus Fair Share. All other businesses under same owner will pay Fair Share only.

2 part-time employees equal 1 full time employee.

Select Business Type

General & Retail Membership (1-49 Employees) $150.00 + $5 Per Employee*$150.00

Base & Fair Share Dues	No. of Memberships/Employees	Price
General & Retail Membership Dues:		$150.00
Fair Share Dues Per Employee:		$5.00

Item subtotal:$0.00

Manufacturing Membership (50+ Employees) $150.00 + $2 Per Employee*$150.00

Base & Fair Share Dues	No. of Memberships/Employees	Price
Manufacturing Membership Dues:		$150.00
Fair Share Dues Per Employee:		$2.00

Item subtotal:$0.00

Real Estate & Professional Financial Membership $150.00 + $50 Per Associate$150.00

Base & Fair Share Dues	No. of Memberships/Associates	Price
Real Estate & Professional Financial Membership Dues:		$150.00
Fair Share Dues Per Associate:		$50.00

Item subtotal:$0.00

Lodging Membership $150.00 + $5 Per Room$150.00

Base & Fair Share Dues	No. of Memberships/Rooms	Price
Lodging Dues:		$150.00
Fair Share Dues Per Room:		$5.00

Item subtotal:$0.00

Restaurant Membership $150.00 + $0.25 Per Seat$150.00

Base & Fair Share Dues	No. of Memberships/Seats	Price
Restaurant Dues:		$150.00
Fair Share Dues Per Seat:		$0.25

Item subtotal:$0.00

Non-Profit Organization Membership$150.00

Individual (Non-Business Owners) Membership$50.00

Total $0.00

How do you want to be billed in the future?

Annuallysemi AnnuallyQuarterly
How do you want to be invoiced in the future?

By MailBy E-Mail
I hereby agree to invest in the future of Moore County Texas by joining the Moore County Chamber of Commerce. I hereby agree to payment of this investment within

30 days of statement and agree that any end all benefits shall cease if we should become 90 days past due.
Company Rep. or Individual E-Signature: (left click & hold on mouse to sign)

Clear
Should be Empty:

Profile Details