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Application

Organization Information (to be displayed online)

Business Name

Address 1

Address 2

City

State

Zip

Phone

Fax

Website

Year Business was established

Description of Business

Main Contact

First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

Additional Contacts

Contact 1

First Name

Last Name

Title

Email Address

Contact 2

First Name

Last Name

Title

Email Address

Contact 3

First Name

Last Name

Title

Email Address

Contact 4

First Name

Last Name

Title

Email Address

Contact 5

First Name

Last Name

Title

Email Address

Contact 6

First Name

Last Name

Title

Email Address

Contact 7

First Name

Last Name

Title

Email Address

Contact 8

First Name

Last Name

Title

Email Address

Contact 9

First Name

Last Name

Title

Email Address

Contact 10

First Name

Last Name

Title

Email Address

Billing Address (if different)

Address 1

Address 2

City

State

Zip

Mailing Address (if different)

Address 1

Address 2

City

State

Zip

Additional Information

Referred By

How did you hear about us?

What is your reason for joining?

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Gift Certificate Program
Member to Member Discount Program
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Membership Investment

Membership Type

Primary Directory Category

Additional Directory Categories

Select additional directory categories below by holding the "CTRL" key
Secondary categories may be added for $25 each

Number of Full Time Employees

Number of Part Time Employees

Number of Rooms

Number of Seats

Number of Associates

Number of Locations

Millions in Assets

Payment Plan Options All payment plans must be paid by credit card that will be automatically charged. Please note that memberships are for one full year. If your membership is cancelled before the full year is complete, you are still responsible for the remainder of the balance for the year.

Payment Plan Options

Enhanced Membership ($50)

Discounts Available

Discount Option

One-Time Application Fee

Tax

Total

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Full-Time Employees

Part-Time Employees

Hotel/Motel Rooms

Restaurant Seats

Additional Associates

Additional Associates Cost

Additional Locations

Additional Locations Cost

Assets

Assets Cost

Additional Categories

Number Of Additional Categories

Additional Categories Cost

Additional Item 1 Cost

Additional Item 2 Cost

Additional Item 3 Cost

Additional Item 4 Cost

Additional Item 5 Cost

Additional Item 6 Cost

Additional Item 7 Cost

Additional Item 8 Cost

Additional Item 9 Cost

Additional Item 10 Cost

Annual Dues (charged to card)

Revenue Item

Tax (charged to card)

Fee (charged to card)

Temp Value For DropDown 1

MembershipType

Additional Item 2

Additional Item 3

Additional Item 4

Additional Item 5

Additional Item 6

Additional Item 7

Additional Item 8

Additional Item 9

Additional Item 10

Additional Categories Cost

Annual Membership Investment

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 MastercardVisaDiscoverAmex

Credit Card Number

Name on Card
Security Code
Valid Through
Address
City
State
Zip
Phone
Credit Card Email Address

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@ Copyright 2014 Southern Rhode Island Chamber of Commerce
230 Old Tower Hill Road, Wakefield, RI 02879 | Phone: 401-783-2801
Fax: 401-789-3120 | [email protected]

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