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Strategic Advocacy
Membership Application Form
Company Name
Company Registration Number
Year Established
Company Contact Person 1 and their Job Title
Title
Select one...
Mr
Miss
Mrs
Other
Company Email Address
Mobile Phone Number
Company Contact Person 2 and their Job Title
Title
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Mr
Miss
Mrs
Other
Company Email Address
Mobile Phone Number
Company Address
Company Mailing Address
Company Website
Company Facebook Page
Company Twitter Page
Office Telephone Number
Fax Number
Business Details
Select the appropriate category that represents your business:
Retail & Distribution
Manufactoring
Agriculture
Accounting
Marketing
Other
Please list the main three products or services offered:
Provide a brief description for your business:
Are there any areas of expertise or interest within your organization which may be useful to the Chamber and you are willing to share? Please provide details.
Are there any special offers you would like to extend to Chamber Members? Please provide details.
Preferred Method of Contact:
Office Telephone
Mobile Phone
Email
Fax
Select a Membership Fee Structure
1-9 Employees - Subscription Rate: $1,000
10-19 Employees - Subscription Rate: $2,000
20-35 Employees - Subscription Rate: $3,000
36-49 Employees - Subscription Rate: $4,500
50+ Employees - Subscription Rate: $10,000
Employee Information
Number of Full Time Employees:
Number of Part Time Employees:
Certificate of Compliance from the National Insurance Corporation
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Applying for:
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Chamber of Commerce Membership
Small Member Support Program
Member Value Program
Southern Members Program
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