MEMBERSHIP APPLICATION

Individual members complete Parts I and III. Individual dues = $40/year

Business members complete Parts II & III. Dues—see schedule.

NAME _______________________________________________________________________

MAILING ADDRESS ____________________________________________________________

CITY ______________________________ STATE _______________ ZIP _________________

E-MAIL ADDRESS _____________________________________________________________

HOME PHONE _________________ WORK PHONE ___________________FAX ___________

Dues are payable in advance. Only one vote is allowed per membership.

Signature________________________________________ Date_________________________

PART II: BUSINESS MEMBERSHIP
(INCLUDING CIVIC, NON-PROFIT, GOVERNMENT AGENCY & FINANCIAL INSTITUTIONS)

BUSINESS NAME ______________________________________________________________

PHYSICAL ADDRESS ___________________________________________________________

MAILING ADDRESS ____________________________________________________________

CITY _____________________________STATE _______________ ZIP __________________

NUMBER OF EMPLOYEES: FULL TIME__________ PART TIME (counts as 2/1) ___________

DUES _________ WEBSITE __________________________ PHONE ____________________

PRIMARY REPRESENTATIVE:

NAME____________________________________________ PHONE ____________________

MAILING ADDRESS____________________________________________________________

CITY ____________________________ STATE _______________ ZIP __________________

E-MAIL ADDRESS____________________________________ FAX _____________________

ADDITIONAL REPRESENTATIVE:

(OPTIONAL—MAY ONLY VOTE AS PROXY FOR PRIMARY REPRESENTATIVE, BUT MAY PARTICIPATE IN MEETINGS, ACTIVITIES, COMMITTEES, ETC.)

NAME____________________________________________ PHONE ____________________

MAILING ADDRESS____________________________________________________________

CITY ____________________________ STATE _______________ ZIP __________________

E-MAIL ADDRESS____________________________________ FAX _____________________

Dues are payable in advance. Only one vote is allowed per membership.

Signature__________________________________________ Date____________

PLEASE INDICATE THE COMMITTEES YOU WISH TO PARTICIPATE IN:

____ Membership

____ Awards & Recognition

____ Transportation

____ Publicity & Marketing

____ Legislative

____ Education & Technology

____ Program Planning

____ Health & Environment

____ Economic Development