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Organization Information
Organization Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Website
Email
Business & Web Site Listing Category
Description of organization
Employees
Full Time Part Time
Note: 40 hours per week constitutes a full time equivalent
Top 3 Reasons You Joined
- Networking Opportunities
- Event/Functions
- Governmental Advocacy for Business
- Economic Development
- Training Opportunities
- Health Insurance
- Selling Products/Services
- Other
Other (please explain)*
Contact Information
Main Contact
Name
First Last
Title
Phone
Email
Additional Contacts
Name Title Phone Email
Investment Schedule
Full Time Employees
- 0-5
- 6-10
- 11-20
- 21-30
- 31-40
- 41-50
- 51-75
- 76-100
- 101-149
- 150+
Government / 501 c(3) Non-Profit Agencies / Civic Organizations / Religious Groups / Membership Organizations
- Yes
- No
Community Member (No Business Affiliation)
- Yes
- No
Associate Member (Retiree or Student)
- Yes
- No
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Total
$0.00

Name	Title	Phone	Email

Organization Information