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Membership Application

 
   
Organization Information (to be displayed online)
Organization Name *
Address 1 *
Address 2
City *
State *
Zip *
Phone *
Fax
Website
Email *
Main Contact
First Name *
Last Name *
Address 1 *
Address 2
City *
State *
Zip *
Title
Phone *
Email *
Additional Contacts
Billing Address (if different)
Street
City
State
Zip
Mailing Address (if different)
Street
City
State
Zip
Additional Information
Keywords
Areas of Interest
*Check all that apply
Business Assistance Information
Economic Development
Government
Networking Events
Special Events
Technology
Tourism
CYP

I understand that by providing my mailing address, e-mail address, telephone number and fax number, I consent to receive communications sent by or on behalf of the Clearwater Regional Chamber (and its affiliates and subsidiaries) via regular mail, e-mail, telephone and/or fax.

Membership Investment
Membership Type: *
Primary Directory Category *
Additional Directory Categories
**Hold CTRL on your keyboard to select multiple categories**
Non Profit (20% Discount):
Number Employees: *  
   
Total: $ 
 
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information below. Thanks.

The contents of this box are for testing purposes. This box will be removed when the form goes live.
Full-Time Employees
Part-Time Employees
Hotel/Motel Rooms
Restaurant Seats
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
AdditionalCategories
Additional Categories Cost
NumberOfAdditionalCategories
additionalItem1Cost
Annual Dues (charged to card)
Tax (charged to card)
Fee (charged to card)
tempValueForDropDown1
Number of Full Time Employees:
Number of Part Time Employees:  
Number of Rooms (Accommodations):  
Number of Seats (Restaurants):  
Number of Associates (Realtors, Attorneys):  
Number of Locations ($35/add. location):  
Millions in Assets (Financial Institutions):  
$ 
$ 
$ 
Credit Card Information
Credit Card Type *
Credit Card Number *             
Name On Card
Security Code
Valid Through
Credit Card Address 1
Credit Card City
Credit Card State
Credit Card Zip
Credit Card Phone Number
Credit Card Email Address
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