Page 15 - Stone Ridge Event Center
P. 15

Membership Application                                            Payment Options

                    DeKalb Chamber Rep:___________________                      Check____Credit Card____
     Company Details                     # of Employees:  _______               Please make checks payable to:

     Company  Name: ______________________________________                   DeKalb Chamber of Commerce
                                                                          Two Decatur Town Center, 125 Clairemont
     ____________________________________________________                   Avenue, Suite 235, Decatur, GA 30030
                                                                                  Federal ID#58-0218054
     Company Rep: ________________________________________                    Memo: Membership Application
     Title: __________________________________ (Incl Salutation)
     Company Address: _____________________________________       I, ____________________________________ (name on card)

     ____________________________________________________         hereby authorize DeKalb Chamber of Commerce to charge my

                   (Special Instructions or Mailing Code:)        debit/credit card account in the amount of $__________  for
     ____________________________________________________         ______________________________ Membership Level.

                   Billing Address:  (if different from above)
     ____________________________________________________                Credit Card Payment Options (Check One)
     ____________________________________________________          _____Visa_____MasterCard_____AmEx_____Discover

     Website URL: _________________________________________         (CC#) _________ - _________ - _________- _________
     Contact #1: ___________________________________________          (CVC#) _________ Exp Date _________  /_________
                      (Name of Main Contact Person)
     Contact Number: ______________ Contact Fax: ______________   Name on Card ____________________________________
     Email Address: ________________________________________      Billing Address ____________________________________

     Contact #1: ___________________________________________      City _______________________ ST _______ Zip ________
                  (Name of Main Contact Person - Optional)        Authorized Signaure _______________________________
     Contact Number: ______________ Contact Fax: ______________
                                                                  Your completion of this authorization form helps us to protect
     Email Address: ________________________________________      you, our valued members from credit card fraud. All information
     Company Listing                                              entered on this form will be kept strictly confidential by
     (select category from below):                                DeKalb Chamber of Commerce. For annual reoccurring payments/
                                                                  monthly subscriptions, your signature authorizes DeKalb Chamber to debit
                                                                  credit card on file for current membership rate at the time of renewal.
     Members are listed in the online membership database, searchable by using
     the categories and key words listed below:                   Member Referral _________________________________
     Arts/Entertainment  Business Services  Construction             (required for member to receive recognition for referral)
     Consumer Services  Education/           Employment             Pay By Check (Please make checks payable to):
                               Non-Profit        Services                       DeKalb Chamber of Commerce
     Financial/Insurance  Government          Healthcare        Attention: Member Services, Two Decatur Towne Center
                                                                    125 Clairemont Avenue, Suite 235, Decatur, GA 30030
     Hospitality/Travel   Legal                 Mfg/Dist
                                                                  Request Invoice*     Annual Reoccurring Payment**
     Marketing/Media     Real Estate           Restaurants/
                                                   Clubs                      Monthly Subscription Payment
                                                                                    *Invoice is due upon receipt.
     Retail              Technology           Transp/Log                **Recurring payment plan available for Partner Level
                                                                                members at an additional cost of $200.
     Utilities           Other                  Other          On receipt of payment a member of the Chamber will contact you to welcome
                                                                  you to the Chamber and ensure that all information received is accurate.
               Key Words: (Provide a minimum 3 key words)
     1  ___________ 2 ___________ 3 ___________                   Thank you for supporting the DeKalb Chamber of Commerce! Your upfront
                                                                  commitment and payment helps the DeKalb Chamber of Commerce increase
                                                                  time spent on delivering programs that support the business community and
     4 ___________ 5 ___________ 6 ___________                    lessen the amount of time spent on raising funds. Thanks to your support, we
                                                                  can get down to the business of making DeKalb County the best community it
                                                                  can be.
     Thank you for your support and future partnership with the DeKalb
     Chamber of Commerce.
   10   11   12   13   14   15   16