Membership Application

Click here for a hard copy of the application

If you have any questions while filling out the application please contact Kelsey at 573-638-3588.

Business or Organization
Business Category *Must choose from list below

Click here for Business Categories

Membership Type
Physical Business Address
City
State
ZIP
Mailing Address (if different from physical address)
City
State
ZIP
Billing Address (if different from physical address)
City
State
ZIP
Business Phone
Fax
Business Info E-mail
Website address
Date Established (MM/DD/YY)
Total # of Employees
Full-Time
Part-Time
Business Description for online directory
Key Words for online directory search
Please select a salutation for your main contact
 Mr.  Mrs.  Ms.  Miss  Dr.
 
Main Contact Name
Title
Main Contact Email
Phone number:
Cell Phone (optional)
Each organization is allowed one member for the base rate, plus one member for each additional $100 paid. Would you like to add another member?
 Yes  No  
If you are adding a secondary member, Please select a salutation
 Mr.  Mrs.  Ms.  Miss  Dr.
 
Secondary Contact Name
Title
Secondary Individual E-mail
Your chamber membership qualifies you for a discounted health insurance rate. Would you like more information about this exclusive benefit?
 Yes  No  I am already a part of the program  
Please share your interests with us:
 Ribbon Cuttings
 Joining a committee
 Young Professionals
 Marketing Opportunities
 Sponsorship Opportunities
 Networking
 Leadership Jefferson City Program
 Professional Development
 Discounted Health Insurance Program
Monday - Friday
8:00 a.m. to 4:30 p.m.
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