Member - Devon & District Chamber of Commerce, AB

Member Application
Business Information

Company Name: *

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Phone: *

Website:

Email: *

Business Description (200 char max): *

Directory Category:

Employees:

Full-time Part-time

Business Keywords (enter a space between words): *

Comments / Questions:

Physical Address

Line 1: *

Line 2:

City: *

Province: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1:

Line 2:

City:

Province:

Postal Code:

Country:

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

Province: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

Province: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Membership: For Profit 1-10 Employees: $125.00
Membership: For Profit 11+ Employees : $200.00
Membership: Not For Profit: $75.00

Payment Option:

Bill me Charge my credit or debit card

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