Membership Application - Fort Collins Area Chamber of Commerce

* Required

Organization Information (to be displayed online)

Organization Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Fax

Website

Email *

Year Established *

Number of Employees (Local) *

Number of Employees (Total) *

Is your business primarily women, veteran, or minority? *

Average age of owner(s) *

Main Contact

First Name *

Last Name *

Address 1

Address 2

City

State

Zip

Title

Phone *

Email *

Additional Contacts

Billing Address (if different)

Street

City

State

Zip

Mailing Address (if different)

Street

City

State

Zip

Additional Information

Referred by

How did you hear about us?

What is your reason for joining? (choose one) *

Areas of Interest

*Check all that apply
Business Advocacy
Marketing & Sponsorship Opportunities
Professional Development & Education
State & Federal Legislation
Transportation
Water
Workforce Development
Other	Required Please enter a valid number Please enter a valid date

Membership Investment

Membership Level: *

Primary Directory Category *

Annual Membership Investment

One-Time Application Fee

Total: $

The contents of this box are for testing purposes. This box will be removed when the form goes live.
Full-Time Employees (Local)
Part-Time Employees
Hotel/Motel Rooms
Restaurant Seats
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
AdditionalCategories
Additional Categories Cost
NumberOfAdditionalCategories
additionalItem1Cost

Annual Dues (charged to card)
Tax (charged to card)
Fee (charged to card)

tempValueForDropDown1

Additional Directory Categories

Primary Directory listing is complimentary
Additional member level based complimentary listing categories:
- Network Plus: 1 additional category
- Promotional:
- Executive:
- Corporate:
- Platinum: 4 additional category
After the complimentary categories, additional Directory listings are $35 each

**Hold CTRL on your keyboard to select multiple categories**

Number of Rooms (Accommodations):

Number of Seats (Restaurants):

Number of Associates (Realtors, Attorneys):

Number of Locations ($35/add. location):

Millions in Assets (Financial Institutions):

Tax

Enhanced Membership ($50):

Additional Categories Cost

Payment Type *

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Credit Card Information

Credit Card Type *

Mastercard

Visa

Discover

Amex

Credit Card Number *

Name On Card	Required
Security Code	Required
Expiration Date
	Use Address Above
Credit Card Address 1	Required
Credit Card City	Required
Credit Card State
Credit Card Zip	Required
Credit Card Phone Number	Required
Credit Card Email Address

Please click submit only one time. The transaction may take several seconds.