Member

Welcome, becoming a member of the Coolidge Chamber is just the beginning of your membership.

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:

Committee Intrest:

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: *

Social Networking:

LinkedIn Facebook

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

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: *

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Individual Membership: $50.00
Individual Membership Non Profit/Government/Clubs Membership: $125.00
Non Profit/Government/Clubs Membership Partnership/Sole Proprietor Membership: $175.00
Partnership/Sole Proprietor Membership Corporation: $225.00
Corporation Business Second Business Membership: $125.00
A Company has 2 or more business you receive the next membership at a flat rate.

Payment Option:

Bill me Charge my credit or debit card

Print Application

Member Application

Mailing Address

Address

Address