Name * First Name Last Name Phone * (###) ### #### Email * Billing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Company Name Industry * Agriculture Data Processing Entertainment Finance Healthcare Hospitality, Food, Travel Information Services Insurance Military Public Service, Social Service Professional Services (Law, consulting, etc.) Retail, E-Commerce Utilities Other Membership Level Student Individual Small Business / Non-Profit Under 100 Employees Academic / Government Corporation Over 100 Employees Age Group * 18 to 24 25 to 39 40 to 60 60 + Gender * Male Female Prefer not to answer Ethnicity American Indian or Alaska Native Asian Black or African-American Latino or Hispanic Native Hawaiian or Pacific Islander White Multiracial Other Prefer not to answer Objectives or Goals List 3 objective or goals you would like to achieve as a chamber member. (Networking, expansion and retention, increase knowledge, etc.) Problems and Solutions List barriers and/or problems you would like to find a solution for. Would you like to attend a new member’s benefits workshop in person or online? * In Person Online Interested in becoming a committee member? Please select the committee you'd like more information about. Advocacy Education Programs Events Fundraising Marketing Membership Would you like to do a ribbon cutting ceremony? (Not applicable for Students or Individuals) Yes No Thank you for completing our survey! Help us get to know you!
