_____ Business Membership        _____ Individual Membership

Firm/Individual Name ___________________________________________

Contact Person _________________________________________________

Physical Address _______________________________________________

Mailing Address ________________________________________________

City __________________________ State _____________ Zip __________

Telephone Number ____________________ Fax Number ______________

Email Address _________________________________________________

Number of Employees ___________________________________________

Type of Business (Please check one)
(   ) Retail    (   ) Wholesale    (   ) Professional Service    (   ) Financial Institute    
(   ) Manufacturing    (   ) Personal Service    (   ) Farming    (   ) Civic Club

Brief Description of Business or Service You Provide ____________________

MEMBERSHIP DUES AND VOTING PRIVILEGES

Type of	Membership       Amount of Dues      Number of Votes

Individual                  $ 50.00               1	
Civic Club                  $ 75.00               1		
State Agency                $ 75.00               1		
Vendor                      $150.00               2	
Churches                    $ 75.00               1

Financial Institution
Total Assets 0 – 25 mil     $350.00		  2
Total Assets 25 – 50 mil    $500.00               4
Total Assets 50+ mil        $650.00               6

Corporate
# of Employees
1 – 2                       $ 75.00               1
3 – 6                       $100.00               1
7 – 12                      $150.00               2
13 - 25                     $200.00               2
26 - 50                     $300.00               3
51 - 100                    $400.00               3
Over 100                    $500.00               4

Amount Paid: ________________
Date Paid: ___________________
Date of Next Billing:___________
Amount to be Billed:___________