2012 On-Line Membership Application
Please take the time to complete this application in order to update our files
and to insure you are on our email list for electronic notices. Thank You!

Listing Information
Firm Name or First and Last Name  
Mailing Address:
Street or PO Box
 
City
       
State
Postal Code
Physical Address:  Leave Blank if same as Mailing Address
Street
City
State
Postal Code
Business Phone
Fax
Toll Free
Email
Website

Personal Contact Information
Contact Name
Title
Phone
  
Fax
Email
May we send you information via fax or email?     Yes   No

Publication / Website Information
Business / Industry Category
(list up to 3 categories):
(example: Gifts, Lodging, Dining)
Brief description of Business
and Services offered:

Membership Level
Click here for Information about the benefits and levels of membership
(Memberships are calendar year based and there is no pro rata for a partial year. Multiple year Business Level Memberships, i.e., Platinum, Gold, Silver and Copper, are encouraged and appreciated.)
Platinum
      $500 year X years
Silver
      $200 year X years
Gold
      $300 year X years
Copper
      $100 year X years
Family   $50 year
 		Individual  $35 year
We welcome additional donations.       Additional Donation Amount $

Method of Payment & Payment Information

Visa        MasterCard       AMEX
Name on Card
Credit Card No
Security Code /V Code  
Expiration Date   
Amount to be charged