LOGAN-HOCKING CHAMBER OF COMMERCE MEMBERSHIP APPLICATION

INFORMATION FOR CHAMBER WEBSITE:

NAME:____________________________________________________________________________

BUSINESS ADDRESS:________________________________________________________________

CITY: ______________________________________   ST: __________  ZIP:_____________________

PHONE: __________________ PUBLIC EMAIL ADDRESS: ___________________________________

WEB ADDRESS: ____________________________________________________________________

TYPE OF BUSINESS (max of 2) _________________________________________________________

FOR CHAMBER USE ONLY:

NAME: ____________________________________________________________________________

MAILING ADDRESS: _________________________________________________________________

CITY: ______________________________________   ST: __________  ZIP:_____________________

PHONE: ________________________________  FAX: ______________________________________

COMPANY CONTACT NAME: __________________________________________________________
(VOTING REPRESENTATIVE)

PRIVATE EMAIL ADDRESS: ___________________________________________________________

MEMBERSHIP YEAR IS JULY 1 – JUNE 30

DUES SCHEDULE (CHECK ONE)

________ SCHEDULE   I -   $ 50                          ________ SCHEDULE V -  VARIES

________ SCHEDULE  II -   $ 35                          ________ SCHEDULE VI  - VARIES

________ SCHEDULE III-   $350                         ________ SCHEDULE VII -  $600.00

________ SCHEDULE  IV-  VARIES                    ________ SCHEDULE VIII-  VARIES

SIGNATURE: __________________________________________________________________________________
Please return with check made payable to: