Business Name ____________________________________ Contact Person ___________________

 

Physical address ___________________________________  Mailing address ___________________

 

City, State & Zip ______________________ Phone # _________________ Fax # ______________

 

Web page address _________________________________________________________________

 

Type of business __________________________________________________________________

 

          Number of full-time employees ____________        Number of Voting Members __________

Names of voting members:                                                            ($120 per voting member)

 

1. _______________________________                      2. ________________________________

 

3. _______________________________                      4. ________________________________

 

5. _______________________________                      6. ________________________________

 

7. _______________________________                       8. ________________________________

 

To help insure the future growth and prosperity of our area I hereby pledge the amount listed below as my Fair Share Investment in the Greater Picayune Area Chamber of Commerce. I understand that dues are payable in advance, and statements are automatically sent out each year for renewal of the membership which begins January 1 of each year.

 

Amount $_________________                          

 

Signature ____________________________________ Title _____________________