M
EMBERSHIP
APPLICATION
General
Information: All
sections must be completed
Business Name
:_____________________________________
Mailing Address:_____________________________________
City________________________State______Zip__________
Street Address:______________________________________
City________________________State______Zip__________
Phone:______________________Fax:___________________
# of local employees: Full time______Part time_____
Company E-mail
for inquiries from the public:
_________________________________________________
Website
:___________________________________________
Employee to be listed in our Membership Directory and
on our
website as
Main Contact:______________________________
_________________________________________________
Title:_____________________________________________
Business/Organization Category:
Choose two from attached list
Primary:___________________________________________
Secondary:__________________________________________
Billing Contact if
different:______________________________
Billing address:______________________________________
City________________________State______Zip__________
What are the three most important things that the
Chamber
can do for you?______________________________________
_________________________________________________
_________________________________________________
Contact Names:
Titles & E-mail for newsletter mailings,
event info & updates on chamber programs.
1)________________________________________________
2)________________________________________________
Contact E-mail
addresses to be used only by the chamber to contact
your company.
1______________________________________________________
_______________________________________________________
2_______________________________________________________
_________________________________________________________
3______________________________________________________
_______________________________________________________
4_____________________________________________________
_______________________________________________________
Business Description
:
25 words or less to be
printed in our Membership
Directory and on our website.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
________________________________________________________
_______________________________________________________
_______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
________________________________________________________
__________________________________________________________
______________________________________________________
______________________________________________________
_______________________________________________________
Please return to: Portland Regional Chamber, 60 Pearl
Street, Portland, Maine 04101-4163
207.772.2811
FAX: 207.772.1179
E-Mail: amazurie@portlandregion.com
www.portlandregion.com