Membership Application Business Name* Contact First Name * Contact Last Name* Title Street Address* Mailing Address City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Phone* Fax Website Email* Preferred Method of Communication EmailFaxMail Number of Employees Full Time Part Time Business Category (Please inquire about your appropriate category and optional purchase of additional categories at $50 each) Who is your customer? What businesses would you like to meet? Referred By Salesperson Date Joined Please state your reason for joining the chamber:* Membership Level Membership Investment One time processing fee Tier III $2,600 Waived Tier II $1,400 Waived Tier I $775 Waived Executive $575 $30 Base Business Membership $425 $30 Additional Franchise $225 $30 President's Club Membership (additional fee) $200 Tier I or above: Brief description of business (up to 100 words) for placement on the website. Please include additional member information (employee name - title - email) Employee Name - Title - Email Investment Level Select One.... Tier III - $2600 Tier II - $1400 Tier I - $775 Executive - $575 + $30 Processing fee Base Business Membership - $425 + $30 Processing fee Additional Franchise - $225 + $30 Processing fee Add a President's Club Membership Select One.... President's Club Membership - $200 Total $ Billing Information Credit Card Type MastercardVisaDiscoverAmex *ALL Credit Card fields below are required* Credit Card Number Name On Card Security Code Valid Through 01 02 03 04 05 06 07 08 09 10 11 12 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Use Address Above Credit Card Address 1 Credit Card Address 2 Credit Card City Credit Card State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Credit Card Zip Credit Card ZipExt Credit Card Phone Number Credit Card Country Credit Card Email Address * I understand that by providing the fax and/or email information above for the business or organization represented in this application, I am authorized to and hereby consent for us to receive faxes and/or e-mails on behalf of the Bonita Springs Area Chamber of Commerce. Membership investment is non-transferable and non-refundable. Please click submit only one time. The transaction may take several seconds.