Membership Application and Renewal Form
Size of
Business
12 Month
Investment
Check
One
Independent Agent
90.00
____
1-3
90.00
____
4-6
120.00
____
7-10
180.00
____
11-19
210.00
____
20-29
240.00
____
30-39
270.00
____
40-99
300.00
____
100+
500.00
____
Utility
270.00
____
Public Agency
270.00
____
Governmental
170.00
____
Non-Profit Organization
30.00
____
Individual
30.00
____
Name of Business: _________________________ Contact Person: _____________________________
Mailing Address:______________________________________________________________________
Business Phone: __________________ Fax: __________________ Personal: _____________________
Email address: ________________________________ Website: _______________________________
Date of Application_________________Membership investment Enclosed: $_______________
Optional Name Tag $10, indicate # of Name tags desired____at $10; Total for Name tags $________
Total Amount Enclosed: $__________________________________
Name to appear on name tag[s], if ordered _________________________________________________
____________________________________________________________________________________
Referred by:
Your Chamber of Commerce dues are deductible from your Federal Income Tax as a necessary business expense. Mail checks to PO Box 83, La Center, WA 98629 or give to any member to submit for you!
La Center North Clark County Chamber of Commerce
Your Community Connection
