Membership Application (Elected Officials)

Date: _____________

Official’s Name / Title: ________________________________________________

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:

______ Elected Official: $50.00

Collinsville Chamber of Commerce
PO Box 245 Collinsville, OK 74021