COMPANY INFORMATION (as you want it to appear online & in publication)
Company Name*

Physical Address*

Physical City*

Physical State*

Physical Zip*

Business Telephone*

Website URL

Business Email*

Billing Address (if different)*

Billing City*

Billing State*

Billing Zip*

CONTACT INFORMATION
Primary Contact*

Primary Contact Title*

Primary Contact Email

Primary Contact Telephone*

Preferred Method of Contact*
EmailPhoneText

Billing Contact*

Billing Contact Title*

Billing Contact Email

Billing Contact Telephone*

Other Contacts
Please list any other employees who should receive our e-newsletter.
Other Contact #1 (Name)

Other Contact #1 (Email)

Other Contact #2 (Name)

Other Contact #2 (Email)

Other Contact #3 (Name)

Other Contact #3 (Email)

Other Contact #4 (Name)

Other Contact #4 (Email)

BUSINESS INFORMATION
Type of Business*
For ProfitNot-For-Profit/School/GovernmentIndividual/AssociateSecond Business

If this is a second business, please list your primary business:

Listing Category (see list)*

20-Word Business Description (for listing on the Chamber website)*

Number of Employees
All employee counts are based on the number of Full-Time Equivalent (FTE) employees in the Sheridan County area (full-time employees=1 FTE; part-time employees=.5 FTE; seasonal=.25 FTE)
Full-Time Employees

Part-Time Employees

Seasonal Employees

Billing Preference:
ElectronicHard Copy

REASON FOR JOINING THE CHAMBER
NetworkingExposureSupport CommunityBecome More InvolvedOther

Thank you for completing this membership application! A Chamber staff member will be in contact with you within 2 business days.

OFFICE USE ONLY
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Revised November 2018