MEMBERSHIP APPLICATION

Company Name: _______________________________ Type of Business: __________________

Address: ______________________________ City:  ______________________ Zip:__________

Phone: _____________________________________  Fax: ______________________________

Email: ___________________________________  Email 2: _____________________________

Web Address:__________________________________________   Number of Employees: ___

Referred By: ___________________________________________________________________

Annual Membership Dues (12 month membership)

Corporate
1-4 Employees
5-19 Employees
20 or more Employees
Chairman's Club
Presidential Advisor
$200
$300
$500
$1000 (available to companies of all sizes)
$2500 (available to companies of all sizes)
 .
Basic membership includes listing of one representative in the membership directory. At the level of 20 or more employees, membership includes listing of an additional representative at no charge. Additional representative(s) may be included at a cost of $35 per representative.
 
Name(s) of representatives: ___________________________________
___________________________________
___________________________________
 
Non-profits: $200 (regardless of the number of employees)
Name(s) of representatives: ___________________________________
___________________________________
___________________________________

Credit Card Type: ______________________________  Name as it appears on card: _____________________

Credit Card #: ____________________  Credit Card Exp: __________ Signature: ________________________

Mail this form with payment to:
Oldham County Chamber of Commerce   P.O. BOX 366   LaGrange, KY 40031

For additional information, or if you have questions, please call or fax:
 Phone: 502.222.1635   Fax: 502.222.3159 (Attention: Member Services Director)