Member Application

Business Information

Company Name: *

Leave Blank:

Phone: *

Website:

Email: *

Business Description (200 char max): *

Directory Category:

Employees: *

Full-time Part-time

Business Keywords (enter a space between words): *

Comments / Questions:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone: *

Fax:

Email: *

Contact Preference:

Email Phone

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone: *

Fax:

Email: *

Contact Preference:

Email Phone

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Print Application

Printed courtesy of www.effinghamcounty.com/ – Contact the Effingham County Chamber of Commerce for more information.
712 N. Laurel Street, Suite 200, Springfield, GA 31329 – (912) 754-3301 – info@EffinghamCountyChamber.org