Member - Southwest Indiana Chamber

Business Information

Company Name: *

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Phone: *

Website:

Email: *

Business Description (324 char max):

Employees: *

Full-time Part-time

Business Keywords (enter a space between words):

Largest market served:

Diverse business status:

Primary purpose for joining:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Social Networking:

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Primary Contact Information

First Name: *

Last Name: *

Title: *

Phone: *

Cell Phone:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name:

Last Name:

Title:

Phone:

Cell Phone:

Email:

Contact Preference:

Email Phone

Login:

Password:

Address

Same as Member Address

Line 1:

Line 2

City:

State:

Postal Code:

Country:

Membership Options

Membership Package: *

HOME-BASED BUSINESS: $250.00
NONPROFIT: $350.00
PARTNER: $455.00
COLLABORATOR: $755.00
TRENDSETTER: $1,500.00
VISIONARY: $3,500.00
PIVOTAL PARTNER: $10,000.00
SIGNATURE CIRCLE: Please contact us to determine the fee.

Payment Option:

Bill me Charge my credit or debit card

Member Application

Mailing Address

Address

Address

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