Membership Application (Business)

Date: _____________

Company Name: ___________________________________________________

Primary Contact Name / Title: __________________________________________

Alternate Contact Name / Title: _________________________________________

Mailing Address: ____________________________________________________

City: _______________________________________ State: _____ Zip: ________

Street Address: _____________________________________________________

City: _______________________________________ State: _____ Zip: ________

Telephone: ________________________ Fax: ___________________________

Cellular: __________________________ Other: _________________________

Email: ____________________________ Website: _______________________

Annual Dues Scale:

___1 - 5 Employees: $150.00     ___ 6 - 10 Employees: $200.00

___11 - 20 Employees: $300.00    ___ 21 - 40 Employees: $400.00

___ 41 + Employees: $500.00

___ Financial Institutions: $500    ___ Utility Companies: $500

Collinsville Chamber of Commerce
PO Box 245 Collinsville, OK 74021
Phone/Fax: (918) 371-4703
Email: info@collinsvillechamber.net

Company Name: ____________________________________________________

Business Establishment Date: ___________________________________________

What is your business’s specialty? _______________________________________

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Why did you decide to open in Collinsville? ________________________________

_________________________________________________________________

Chamber Member Since: ______________________________________________

Have you ever held office with the Chamber, or served on a committee? ___________

_________________________________________________________________

Are you currently a member of any other organizations? _______________________

_________________________________________________________________

Please add any other information you would like us to know about your business:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Note: The information in this profile will be used to help us represent your business to the community and potential customers.