Alliance Area
Chamber of Commerce

Business Name: __________________________________________________
Address: ________________________________________________________
City:   ______________________ State: ____________ Zip:________________
Telephone:_____________________Fax: ______________________________
Email ______________________________ Web Site: ____________________

Primary Representative: _____________________    Title: __________________

Additional Representatives:

________________________Title: ______________ Email: _________________
________________________Title: ______________ Email: _________________
________________________Title: ______________ Email: _________________
________________________Title: ______________ Email: _________________

Contact Preference: ____ Email ____ Telephone ____Fax ____Regular Mail

Please give a brief description of your business: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Number of employees: ____
Type of Business: _____________________________(Determines directory listing category)

Membership Annual Investment: $____________ (Click here for investment schedule)

Circle Payment Method:     Cash     Check - Check #:____ Credit Card
_____ Visa _______ Mastercard

Card #:___________________________                             Expiration Date:________

Cardholder's Name:__________________Signature:_________________________

Membership investments are paid in advance and automatically invoiced each year.
Please note that dues may be considered ordinary and necessary business deductions
but are not deductible as charitable contributions for income tax purposes.