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Membership Registration Form

Business Name*
Business Type*
Date Established*
Address*
City*
State*
Zip*
Country*
Phone (Day)*
Phone (Mobile)
Company Email (for online directory)*
Web Address*

User Credentials

Desired Username
Desired Password

Primary Contact

Prefix
Name*
Title*
Phone*
Email*

Secondary Contact

Name*
Title*
Phone*
Email*

Alternate Billing Contact

Name
Title
Phone
Email

Diverse Business Categories (51% or more ownership)

 Women Owned
 Native American
 Hispanic
 Veteran Owned
 Asian Pacific
 Asian Indian
 Black

Brief description of your business

Membership rates:
 
The base membership rate is $450 and is based off number of full-time employees. For calculation purposes, two part-time employees equal one full-time employee.
Member Dues
Amount Due
$

Payment Information

Payment Method
Card Type
Name on Card
Card Number
CVV
Expiration

Contact Information

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