Business Name*

Primary Contact Person*

Title

License Number

Business Address*

City, State, ZIP*

Mailing Address (if different from above)

City, State, ZIP

Primary Phone Number*

Secondary Phone Number

Business Fax Number

Business Website

Primary Email Address*

Confirm Email Address*

Business Category
Please Select One Advertising & Media Agriculture, Fishing & Forestry Arts, Culture & Entertainment Automotive & Marine Business & Professional Services Cleaning Services Computers & Telecommunications Construction Equipment & Contractors Event Planning Family, Community & Civic Organizations Finance & Insurance Government, Education & Individuals Health Care Home & Garden Lodging & Travel Manufacturing, Production & Wholesale Personal Services & Care Public Utilities & Environment Real Estate, Moving & Storage Religious Organizations Restaurants, Food & Beverages Shopping & Specialty Retail Sports & Recreation Transportation

Business Description (25-Word Limit)

Please note: The words in this description are also used in the Member Online
Directory Keyword Search, so concentrate on words potential customers might
use in searching for your business.

Reason for joining the Chamber
Please check which Chamber benefits are most important to your business.

Business Assistance and Advice
Professional Development/Training (Seminars)
Marketing/Advertising Opportunities
Networking/Generating New Business
Directory Listings/Phone Referrals
"Clarion" Newsletter
Member Discounts
Business Advocacy
Community Involvement and Support
Other:

Referred By

Areas of Interest
Please check which group or activities of interest

Ambassadors
Business/Education
Golf Tournament
Citizen of the Year Gala
Employee Appreciation Lucheon
CornFest
Hometown Halloween
Holiday Parade
Other: