Please fill out the information in the form below and someone will get back to you regarding your application. Membership charges are as follows:

1 – 3 Employees …………………………	$160
4 – 10 Employees ………………………	$185
11 – 20 Employees ……………………	$210
21 – 50 Employees ……………………	$260
51 – 150 Employees …………………	$310
151 & over Employees ………………	$410

Firm/Individual
Date Established Locally
Total Local Employment
Telephone
Fax
E-Mail
Website
Street Address
City
State
Zip Code
Chief Executive
Business Description
Business Type	DBA Sole Proprietor Corporation
Designated Member Name
Title
Sponsor