Member

Business Information

Company Name: *

Leave Blank:

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: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Social Networking:

LinkedIn Facebook Twitter

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook Twitter

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

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 Twitter

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Associate Member: $75.00
Government Agencies Civic Organization Not For Profit Introductory Member: $125.00
This is for members who have never been in the Chamber before. Business and Others: $200.00
This is for a member who has already been a member of the Lodi & Lake Wisconsin Chamber.

Payment Option:

Bill me

Member Application

Mailing Address

Address

Address

608.592.4412

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