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Membership Registration Form

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

Primary Contact

Prefix
Name*
Title*
Phone*
Email*

Secondary Contact

Name
Title
Phone
Email

Alternate Billing Contact

Name
Title
Phone
Email
Number of Employees
Diverse Business Categories (51% or more ownership)
 Women Owned
 Native American
 Hispanic
 Veteran Owned
 Asian Pacific
 Asian Indian
 Black

Reason for joining
I want to...

 Build
  • Serve with business leaders on committees
  • Expand your network
  • Meet new customers and clients
 Access
  • Brand visibility and credibility
  • Money-saving benefits
  • Access to information and resources
 Advocate
  • Have a voice in shaping public policy
  • Encourage inclusive workplace cultures
  • Support quality education
 Invest
  • Give back to the community
  • Strengthen the local economy
  • Impact the quality of community life
Brief description of 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.
 
Banks/credit unions are based off annual deposits. 
Business Type
Annual Deposits $
(in millions)
Amount Due $

Credit Card Information

Card
Name on Card
Card Number
CVV
Expiration

Contact Information

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