Jefferson Chamber of Commerce

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Application for Membership

GENERAL INFORMATION
Company Name:			DATE:
Physical Address:
City:	State:		Zip:
Mailing address (if different from Street Address):
City:	State:		Zip:
I would prefer that my information be sent to Physical address Mailing address
Telephone:	Toll-Free:		Fax:
E-Mail Address: Web-Site Address:
Number of Employees: Full-time Part-time
Year Business Established:
Minority Owned? Yes No		Woman Owned ? Yes No
Business Categories - Click here to view our Business Categories and type your selections in the field below:
Choose maximum of two (2) choices from the Business Categories Directory.

COMPANY REPRESENTATIVES
CEO /Owner's Name:
Job Title:	Email:
Telephone:	Fax:	Cell:
Please provide address, if different from the one listed above:
Address:
City:	State:	Zip:
Will the CEO/Owner listed above serve as your primary reprsentative? Yes No
Primary Representative
Telephone:	Fax:	Cell:
Job Title:	Email:
Please provide address, if different from the one listed above:
Address:
City:	State:	Zip:
Other Representative
Telephone:	Fax:	Cell:
Job Title:	Email:
Please provide address, if different from the one listed above:
Address:
City:	State:	Zip:

* Please complete the following section for multiple other2 representatives to be included in our membership database

Other Representative
Telephone:	Fax:	Cell:
Job Title:	Email:
Please provide address, if different from the one listed above:
Address:
City:	State:	Zip:

Other Representative
Telephone:	Fax:	Cell:
Job Title:	Email:
Please provide address, if different from the one listed above:
Address:
City:	State:	Zip:

Referred by (Chamber Member's Name):

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