Please check one:  New Member _____  Renewal _____ 

Please check one:  Business ($75.00) _____  Individual ($30.00) _____ Non-Profit ($30.00) _____

Business Name: _____________________________________________________________

Owner's Name: _____________________________________________________________

Comtact Name:  ___________________________________________________________

Business Mailing Address: ____________________________________________________

                                    City: ______________  State:  __________  Zip:  ________________

Business Street Address: _____________________________________________________

                                    City: ______________  State:  __________  Zip:  ________________

Business Phone: (          ) __________________  Fax: (          ) ________________________

E-Mail Address: ________________________  Home: (          ) _______________________

Business Web Site: __________________________________________________________

Type of Business: _______________________________ Year Established: _____________

Your Position: Owner __ Partner __ CEO __ Manager __  Employee __ Other __________

Number of Employees:  Full Time ____________  Part Time ______________

Briefly describe type of service or products sold: __________________________________

Would you be interested in serving as a Director? Yes ____  No ____

Today's Date: ________________       Membership Renewal Date: ___________(Office Use Only)

Your Signature: ____________________________________________________________

Office Use Only:
Date Received:  __________ Name: __________ Payment: __________ Check # _______