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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
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