Membership Application

Primary Contact Name

First Last

Primary Contact Title (ex. owner, CEO, etc.)

Primary Contact Phone Number*

If your primary contact has a cell number or direct line, please enter it here.

Primary Contact Email Address*

Enter Email Confirm Email

Please enter a valid email address for your primary contact

Billing Contact Name

If the billing contact is different than the primary contact, please provide their information.

First Last

Billing Contact Email

Name of Business / Organization

Brief Description of Business (i.e., type of business, services offered, etc.)

Physical Address of Business (NOTE: this addresss will be displayed in our membership directory)

Street Address Address Line 2 City State ZIP Code

Mailing Address of Business

If your mailing address is different than the physical location of your business, please enter it here.

Street Address Address Line 2 City State ZIP Code

Primary Business Phone Number

This is the number that will be listed in our membership directory.

Company Website or Social Media Page

Total Number of Employees

If you would like to offer a Member to Member discount, please describe your offer

Tell us why you would like to join the Liberty County Chamber of Commerce

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