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Organization Information (to be displayed online) Organization Name Address 1 Address 2 City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Phone Fax Website Email Main Contact Copy from Organization Information First Name Last Name Address 1 Address 2 City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip County Title Phone Email Billing Contact Copy from Main Contact First Name Last Name Title Phone Email Additional Contacts Contact 1 First Name Last Name Title Phone Email Address Contact 2 First Name Last Name Title Phone Email Address Contact 3 First Name Last Name Title Phone Email Address Contact 4 First Name Last Name Title Phone Email Address Contact 5 First Name Last Name Title Phone Email Address Contact 6 First Name Last Name Title Phone Email Address Contact 7 First Name Last Name Title Phone Email Address Contact 8 First Name Last Name Title Phone Email Address Contact 9 First Name Last Name Title Phone Email Address Contact 10 First Name Last Name Title Phone Email Address Add/Remove Contacts Billing Address (if different) Address 1 Address 2 City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Additional Information Referred By What is your reason for joining? Employee Range 1-10 11-50 51-200 201-500 501-1000 1001-5000 5000+ Do you qualify as a minority-owned business? No Yes If yes, please explain. Are you interested in sponsoring events? No Yes I would like to learn more about Sponsorship and Marketing Opportunities Cost Savings Programs Anthem SMART Healthcare Plan Government Relations Economic Development Events Membership Investment Membership Type Select one... Contributor $500 Advocate $2500 Patron $5000 Cornerstone $12,500 Leadership $25,000 Chair's Circle $50,000 Pinnacle $100,000 Primary Directory Category None Advertising, Marketing, PR and Media Agri-Business and Agriculture Automotive Banking, Finance and Insurance Board of Directors Board of Governors Business and Professional Services Chambers of Commerce and Development Authorities Construction, Architects, and Engineers Consumer Goods and Services Education Government Healthcare Hospitality and Tourism Information Technology and Internet Services Legal Logistics Manufacturing Non-profit, Foundations, and Associations Real Estate Restaurants and Catering Retail Sports and Entertainment Storage Technology Trade and Services Transportation Utilities and Environment Additional Directory Categories Select additional directory categories below by holding the "CTRL" key Secondary categories may be subject to additional fees none Annual Membership Investment Additional Items Additional Categories Cost One-Time Application Fee Tax Total The contents of this box are for testing purposes. This box will be removed when the form goes live. Full-Time Employees Part-Time Employees Hotel/Motel Rooms Restaurant Seats Additional Associates Additional Associates Cost Additional Locations Additional Locations Cost Assets Assets Cost Additional Categories Number Of Additional Categories Additional Categories Cost Additional Item 1 Cost Additional Item 2 Cost Additional Item 3 Cost Additional Item 4 Cost Additional Item 5 Cost Additional Item 6 Cost Additional Item 7 Cost Additional Item 8 Cost Additional Item 9 Cost Additional Item 10 Cost Annual Dues (charged to card) Revenue Item Tax (charged to card) Fee (charged to card) Temp Value For DropDown 1 MembershipType Additional Item 1 Additional Item 2 Additional Item 3 Additional Item 4 Additional Item 5 Additional Item 6 Additional Item 7 Additional Item 8 Additional Item 9 Additional Item 10 Payment Type Credit Card Check NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks. Number of Full Time Employees Number of Part Time Employees Number of Rooms Number of Seats Number of Associates Number of Locations Millions in Assets Credit Card Information Copy from Organization Information Credit Card Type MastercardVisaDiscoverAmex Credit Card Number Name on Card Security Code Valid Through 01 02 03 04 05 06 07 08 09 10 11 12 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Address City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Phone Credit Card Email Address Please click submit only one time. The transaction may take several seconds. Please select a membership type before submitting your application. (Visited 177,879 times, 130 visits today)