MEMBERSHIP APPLICATION

Date Entered: ________________________

Business: ___ Individual: ___ Corporation: ___ Associate: ___

Membership Pd: ___ Amount: __________ Senior exempt: ___ Non Profit Org: ___

Business Information:

Business Name: ______________________________________________________

Street Address: ____________________________________________

City: _________________________ State: _______ Zip Code: ______________

Phone(s): __________________________ Fax: __________________________

__________________________

URL (website address): ________________________________________

E-Mail: ____________________________

Contact Persons Information:

First Name: ____________________________ Last Name: ___________________________

Mailing Address: ___________________________________________

City: _________________________ State: _______ Zip Code: ______________

Phone: ____________________________

E-Mail: ____________________________ E-Mail #2: __________________________

Comments:

Business Type: ________________________________________________________________

Sidelines: _____________________________________________________________________

Committees (please “x” all that you will support this year)

Memberships: ___ Business Development: ___ Community Revitalization: ___

Economic Dev: ___ Merchants: ___ Shop @ home: ___ Tourism: ___

Prospector’s Days: ___ Fun Run: ___ Barrel Derby Days: ___ none: ___

Other Interest: _________________________________________________________________

DUES STRUCTURE

An employee is defined as those who work full time of a combination of those working part-time whose total hours worked equals 40 hours per week. Employers with multiple business interests may count their total employees as a single group for a more favorable dues structure. Each business interest listed below will be considered and advertised as a member of the chamber.

FOR DUES STRUCTURE PLEASE CHECK OUR WEBSITE AT www.republic-wa.com/membersh.htm.