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:

Woman Owned?:

Veteran Owned?:

Minority Owned?:

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

Login: *

Password: *

Social Networking:

LinkedIn Facebook Twitter Instagram google+

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

Login:

Password:

Social Networking:

LinkedIn Facebook Twitter Instagram google+

Address

Same as Member Address

Line 1:

Line 2

City:

State:

Postal Code:

Country:

Membership Options

Additional Fees:

Administration Fee : $50.00
One-Time Administration Fee (required of all new memberships)

Additional Opportunities:

We will contact you with additional information.

Additional Listings : $150.00
Note: Additional Listings must include the primary membership but may have separate contact information. Example:ABC/HVAC/Additional Listing: ABCHVAC/Chimney Cleaning. If 5 or more Additional listings are desired please call the Madison Chamber of Commerce Office for assistance.

Payment Option:

Charge my credit or debit card

Member Application

Mailing Address

Address

Address