Brockville and District Chamber of Commerce Application Form

Company:
Address:
City:
Postal Code:
Telephone:
Toll Free:
Fax:
E-mail:
Website:

Preferred Methood of Contact:	E-mail Fax Mail

Number of Employees (2 P/T = 1 F/T):
Business established in (year):

BUSINESS CATEGORY:

1. Choose one:	Service Retail Manufacturing Wholesale/Distribution

2. Choose one:	Home Based Small Business Business (15+) Institution Industry

3. Choose as many as apply:	Downtown Professional Multi National Tourism-Oriented Non Profit Government Independent Hospitality Franchise
Business Directory Listing: One word that best describes your business (your yellow page word)

Business Directory Description: 30 words or less to describe your business in the directory

M2 Benefit Program:	Yes No

Would you like to take advantage of the opportunity to offer an exclusive benefit or discount to Chamber Members and their employees?
If yes, please describe:
Contacts: Please include their full name, title and e-mail
Contact 1:
Contact 2:
Contact 3:
Contact 4:

How were you made aware of the Brockville and District Chamber of Commerce?

Please state your main reason for wanting to join the Chamber: