Membership Application

   
Organization Information (to be displayed online)
Organization Name *
Address 1 *
Address 2
City *
State *
Zip *
Phone *
Fax
Website
Email *
Main Contact
First Name *
Last Name *
Address 1 *
Address 2
City *
State *
Zip *
Title
Phone *
Email *
Additional Contacts
Billing Address (if different)
Street
City
State
Zip
Mailing Address (if different)
Street
City
State
Zip
Additional Information
Referred by
How did you hear about us?
What is your reason for joining?
Smoky Hill Gift Certificate Participant? *
Please have someone contact me regarding
*Check all that apply
Business Resources
Community Involvement
Cost Savings Programs
Economic Development
Government Relations
Networking
Other           
Membership Investment
Membership Type: *
Primary Directory Category *
Secondary Directory Category
3rd Directory Category
Number of FTE Employees:
(Full Time Employees (FTE) is = Total hours worked by all employees in 1 week divided by 40.)
 
Number of Professionals:  
Number of Customers (Utilities):  
Millions in Deposits (Financial Institutions):  
   
Total: $ 

The contents of this box are for testing purposes. This box will be removed when the form goes live.
Full-Time Employees
Part-Time Employees
Hotel/Motel Rooms
utilities
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
AdditionalCategories
Additional Categories Cost
NumberOfAdditionalCategories
additionalItem1Cost
Annual Dues (charged to card)
Tax (charged to card)
Fee (charged to card)
tempValueForDropDown1
Additional Directory Categories
**Hold CTRL on your keyboard to select multiple categories**
Number of Part Time Employees:  
Number of Rooms (Accommodations):  
Number of Locations ($35/add. location):  
Enhanced Membership ($50):
$ 
$ 
$ 
*
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.
Credit Card Information
Credit Card Type *
Credit Card Number * 
Name On Card
Security Code
Valid Through
Credit Card Address 1
Credit Card City
Credit Card State
Credit Card Zip
Credit Card Phone Number
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