Printable Chamber Membership Form

Date_____/_____/____

Business or Firm

______________________________________________________________________________

Assign Membership to

Title

______________________________________________________________________________

Business Address

______________________________________________________________________________

Street

PO Box

______________________________________________________________________________

City

State

Zip

Phone: _________________________________

Fax::_________________________________________

E-Mail ___________________________________

Web: ___________________________________________

Number of Employees:

____ Full-Time ____ Part-Time

Business Classification: _________________________

This membership proposed by: ______________________________________________

Investment Amount: _______________ Check Cash

___ Payable Annually

____ Semi-Annually

___ Quarterly by Bank Draft(must include first quarter)

Visa Mastercard

Expiration Date: _________________

Account # _______________________________

Name on Card: _________________________________________________

Membership dues payments are deductible by members as an ordinary and necessary business expense. Contributions or gifts to the Jefferson City Area Chamber of Commerce are not deductible as charitable contributions for federal income tax purposes.

Office Use Only
Date Received _______________	Amount Received _________		Type of Payment _______	Initial ____
Clipboard Date_______________	Initial ________
Entered on Compass___________		Initial ________	Classification Code _______________

Jefferson City Area Chamber of Commerce
213 Adams Street, PO Box 776
Jefferson City, MO 65101
(573) 634-3616 Fax: (573) 634-3805