Business Name:____________________________

Your Address (As you would like it to appear):____________________________

Please Cheack Appropriate Business Category:

Manufacturing/Industrial:__________
Sales/Service:__________
Proffessional:___________
Retail Business:__________
Recreation/Tourism:___________
Construction/Contractor:___________
Non-Profit Organization:___________

Phone Number::____________________________

Fax Number::____________________________

E-mail Address::____________________________

Web Page Address::____________________________

Designated Repesentative:____________________________________
Title:______________________________________________________

Please put and "X" by the selection you yould like to help with:
_____ Yes I would like to help, just let me know what I can do.
_____ Yes I would like to be considered for a board member.
_____ Yes I would like to serve on a chamber committee.