Member Application

Welcome to the Greater Beauregard Chamber of Commerce, we are pleased to have you and your company as a new member.

Business Information

Company Name: *

Leave Blank:

Phone: *

Website:

Email: *

Business Description (200 char max): *

Directory Category:

Employees:

Full-time Part-time

Business Keywords (enter a space between words): *

Comments / Questions:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1:

Line 2:

City:

State:

Postal Code:

Country:

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Commerce & Industry: $200.00
Any business having over 200 employees Business: $175.00
Any business having less than 200 employees Non Profit-Churches: $125.00
Any church, non-profit or civic group Individual: $75.00
Person not over 65 or military that would like to become a member of the Chamber. Retired/Military: $50.00
Any person over the age of 65 or Military.

Payment Option:

Bill me Charge my credit or debit card

Print Application