Application Form

First Name

Last Name

Address

City

Zip/Postal Code

Email Address*

Phone*

Fax

Company Name:

Website (do not include http://):

Preferred Method of Contact:

E-Mail

Phone

Fax

Mail

# of Employees (2 P/T = 1 F/T):

Business established in (year):

BUSINESS CATEGORY:

Choose one:

If "Other", please specify

Search Engine Keywords (6 words max)

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

M2 Benefit Program:

M2M Benefit Details:

CONTACT: *Please include their full name, title and e-mail*

Contact 1:

Contact 2:

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

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

July 1, 2014 Canada enforced a new anti-spam legislation which will regulate the distribution of electronic messages. To comply with this new law, we request your consent to send you valuable e-communications such as upcoming events, chamber updates, and offers from our members.

Do you wish to recieve e-communications from the Brockville & District Chamber of Commerce?