MEMBERSHIP  APPLICATION

Company Name: _______________________________________________________

Physical Address: _______________________________________________________

City, State & Zip: _______________________________________________________

Mailing Address: ________________________________________________________

City, State & Zip: _______________________________________________________

Phone: ____________________________     Fax: ____________________________

E-Mail: _______________________________________________________________

Permission for The Chamber to e-mail: Yes   No

Web Site Address: ______________________________________________________

Type of Business: ______________________________________________________

Products/Services: _____________________________________________________

Number of Employees: Full Time: _____ Part Time: _____ (2 part time employees equal 1 full time)

Main Representative: ____________________________ Title: ___________________

E-mail: ____________________________ Phone: ____________________________

Secondary  Representative: _______________________ Title: ___________________

E-mail: ____________________________ Phone: ____________________________

2013 Chamber Investment: ____________________________

Yearly Online Business Directory Enhancement: Color Highlight ($50)   Logo ($70)                                                                                              Both ($100)

Form of Payment: Check   MC    Visa    AMEX    Discover

Credit Card Number: ____________________________________________________

Name of Cardholder: ____________________________________________________

Expiration Date: _______________________    Billing Zip: _______________________

Signature: ____________________________ Date: ___________________________

If mailing, please send membership form and payment to: The Greater Hot Springs Chamber of Commerce, 659 Ouachita Ave., Hot Springs, AR 71901