MEMBERSHIP FORM
CHAMBER OF COMMERCE
Website: www.fortpayne.com / E-mail: fpchamber@fortpayne.com
STREET ADDRESS ____________________________________________________
CITY _____________________ STATE ______________ ZIP__________________
PHONE NUMBER _______________________ FAX NUMBER ________________
MAILING ADDRESS (if different from above) __________________________________
EMAIL ADDRESS ______________________________________________________
WEBSITE ADDRESS ____________________________________________________
TYPE OF BUSINESS _____________________________________________________
NAME OF REPRESENTATIVE ____________________________________________
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WE INTEND TO JOIN THE CHAMBER, OUR CHECK WILL BE MAILED FROM CORPORATE OFFICE.
________________________________________________________
(signature of company representative)
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The chart below should be used to determine the amount of your investment:
1. General Employers
Number of Employees Rates
1 thru 5 $100
6 thru 10 125
11 thru 25 ..175
26 thru 50 ..225
51 thru 100 300
101 thru 200 ..375
201 thru 300 ..450
301 thru 400 ..525
401 thru 500 600
500+ ……600 plus $1 for each additional employee over 500
2. Individuals and clubs ..$50
3. Utilities (gas,electric,water,telephone) .$400
4. Financial Institutions (based on assests)
1 thru 5 million ..$300
6 thru 10 million 400
10 thru 15 million ..500
15+ million . 600