You are on page 1of 2

COMPANY NAME

PHYSICAL ADDRESS

MAILING ADDRESS

TELEPHONE

FAX

EMAIL

WEBSITE

FACEBOOK PLEASE LIST ADDITIONAL CONTACTS ASSOCIATED WITH YOUR BUSINESS THAT SHOULD BE INCLUDED ON THE CHAMBERS DISTRIBUTION LIST FOR NOTIFICATION OF MEETINGS AND SPECIAL EVENTS. PLEASE INCLUDE NAME AND EMAIL ADDRESS. 1. 2. 3. 4. 5. DESCRIPTION OF BUSINESS

# FULL TIME EMPLOYEES

# PART TIME EMPLOYEES

DUES INVESTMENT SCHEDULE { } COUNTY/TOWN GOVERNMENTS (.50 PER CAPITA BASED ON MOST RECENT CENSUS) .50 X ________________ (POPULATION) = $____________________ } Non-Profit Non-Government Subsidized $50 } Non-Profit Quasi-Government $200 } Base Rate $100 (up to five full-time employees/2 part-time employees equals 1 full-time) + $6 for each additional employee $100 (up to five employees) $100.00 Number of employees above five___________ X $6.00 = ________ Total $ } Individual Membership $75 } Utilities: Small $200/Large $350 } Industries: $100 per Million Dollars in Gross Revenue ($2500 Max.) _____________ Total Gross Revenues X $100 per $Million = ___________________ } 90-DAY TRIAL MEMBERSHIP (FREE TO NEW BUSINESSES)

{ { {

{ { {

YOUR ANNUAL INVESTMENT IS DEDUCTIBLE AS A BUSINESS EXPENSE AND WILL BE DUE ON JANUARY 1 OF EACH YEAR. IF YOU ARE SUBMITTING A NEW APPLICATION, PLEASE CONTACT THE CHAMBER OF COMMERCE AT (276) 889-8041 FOR THE PRO-RATED AMOUNT FOR YOUR FIRST YEAR OF MEMBERSHIP.

AMOUNT ENCLOSED

CHECK NUMBER

SIGNATURE OF APPLICANT/PRINTED NAME & TITLE

DATE