MEMBERSHIP INFORMATION

    Business Name   

   Street Address     

    City     State          Zip

   Effective Date  mm/dd/yy

  Telephone        Fax      Email

  Website: 

 BILLING OFFICE INFORMATION  (If different from above)

   Billing Office Name 

   Address
 
  City     State     Zip 

 DIRECTORY LISTING INFORMATION (see Investment Structure below)
 
 Category 1st Listing 

 Category 2nd Listing  ($20 additional)

 Expand on your product or service (50 characters maximum, including spaces)
                                                    

 REPRESENTATIVE'S INFORMATION

  Primary Contact 

  Title

 Addition Contact

  Title

INVESTMENT STRUCTURE

 Group I - General/Industrial:  Includes manufacturers, Processors, Real Estate Agencies, Insurance     Agencies, Radio, Newspapers, Hospitals, Wholesalers, Distributors, and All Firms Selling on a Retail  Basis, Agricultural and Forestry Producers, Providers of Services, and Individuals.

Part-time employees are classified as those that work 20 hours or less per week.  Two (2) part-time employees is equivalent to one full-time employee in determining the number of employees. The owner and his family member who work at the business are counted as employees. 

Group IV - Professional Services:  (Includes Medical Doctors, Nurse Practitioner, Dentists, Optometrists, Orthodontists, Chiropractors, Radiologists, Veterinarians, Physical Therapists, Attorneys, Accountants, Engineers, Surveyors, Geologists) 

INVESTMENT SCHEDULE (See Investment Structure above)

 Group   I II III IV V     Number of Employees     Annual Investment 

 Please make check payable to:
                            
                         Andalusia Area Chamber of Commerce
Mailing address: P.O. Box 667
                          Andalusia, AL 36420

Thank you for your investment in the Andalusia community!
You will be contacted by the Andalusia Area Chamber of Commerce