Company Name
Contact Name
Title
Address
City, State, Zip
Phone:
Fax
E-Mail
Classification
Community Organization / Non-Profit - $105.00/YEAR
Individual (Retired, Not Business Related) - $105.00/YEAR
Sole Proprietor - 0 Employees - $160.00/YEAR
Commercial Business - 1 to 5 Employees - $185.00/YEAR
Commercial Business - 6 to 15 Employees - $210.00/YEAR
Commercial Business - 16 to 25 Employees - $265.00/YEAR
Commercial Business - 26 to 99 Employees - $370.00/YEAR
Commercial Business - 100+ Employees - $525.00/YEAR
Government / Education - $100.00/YEAR
Associate Dues - $75.00
NEW Member Fee
$25.00
Credit Card Type
MASTER CARD
VISA
AMERICAN EXPRESS
DISCOVER
Credit Card #:
Expiration Date
01
02
03
04
05
06
07
08
09
10
11
12
/
2000
2001
2002
2003
2004
2005
Name On Card
# Employees
Web Site
Referred By
Business Description
I'm interested in information about being involved in:
Membership Committee
Ambassador Committee
Economic Prosperity Committee
Legislative Committee
Canal Development Committee
Organization Image Committee
Annual Awards Banquet Committee
Please fill in above fields and print and then fax this to (585) 227-7275
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