Greater Newburyport Chamber of Commerce & Industry 38R Merrimac Street, Newburyport, MA 01950 Phone: 978-‐462-‐6680 Fax: 978-‐465-‐4145
[email protected]
________________________________________________________________________________________________________ ~ APPLICATION FOR CHAMBER MEMBERSHIP ~ Today’s Date_______ Company Name: _________________________________________________________________________________________________ Physical Address: _________________________________________________________________________________________________ City: ___________________________________________________________ State: ____________ Zip Code: __________________ Mailing/Billing Address (if different): _________________________________________________________________________________ Telephone: (_______)______________________________________ Fax: (________)______________________________________ Website: ________________________________________ General Business E-‐mail: ________________________________________ Facebook : _______________________________ Twitter: _________________________ Linked In: _________________________ Representative Information * Please write on the back of this form the names and email addresses of any other employees/colleagues who you would like to receive chamber emails and event notices. Primary Contact: ______________________________________________________ Title: ___________________________________ Primary Contact E-‐Mail: ___________________________________________________________________________________________ Secondary Contact: _____________________________________________________ Title: ___________________________________ Secondary Contact’s E-‐Mail: ________________________________________________________________________________________ Business Category – Choose One ________________________________________________ nd {A 2 category listing may be purchased for an additional $50, all others after that are $25 each.} Business Description – Required: ____________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Year Bus. Established: __________ # of Full Time Employees: _________ # of Part Time Emp: (less than 30 hrs): _________ Business Hours: __________________________________________________________________________________________________ Membership Fee: $___________________ (Please see “Your Investment” sheet to calculate. Based on # of employees) Payment Method: ! Check ! MasterCard ! Visa ! Amex ! Monthly EFT* *If monthly electronic funds transfer, enclose voided check with your signed EFT form and membership application Card Number: __________________________________________________________________________ V Code: ________________ Expiration Date: _______/________ Cardholder Signature: ________________________________________________________
What issues face your business currently? ____________________________________________________________________________ ________________________________________________________________________________________________________________ What is your primary reason for joining the Chamber? ! Networking/Business Contacts ! Website Link ! Information/Education !Lobbying/Advocacy ! Community Involvement ! Social/Entertainment purposes ! Other (explain) ____________________
I agree to receive emails from the Chamber. Signature: ____________________________________________________
