Membership Application

 
   
Organization Information (to be displayed online)
Organization Name *
Address 1 *
Address 2
City *
State *
Zip *
Phone *
Fax
Website
Email *
Main Contact
First Name *
Last Name *
Address 1 *
Address 2
City *
State *
Zip *
Title
Phone *
Email *
Additional Contacts
Billing Address (if different)
Street
City
State
Zip
Mailing Address (if different)
Street
City
State
Zip
Additional Information
Business Classification
(Please Check the classification that best describes your business)
Please tell us why are you joining the Merrimack Valley Chamber?
*Check all that apply
Networking & New Business Contacts
Government Affairs/Access
Members Only Referrals & Sales Opportunities
Members Only Discounts
Group Benefits Health/Dental Insurance etc.
Other           
Membership Investment
Membership Type: *
Primary Directory Category *
Number of Full Time Employees:  
Number of Part Time Employees:  
Number of Rooms (Accommodations):  
Number of Seats (Restaurants):  
Square Ft. (Thousands):  
Millions in Assets (Financial Institutions):  
   
$ 
Total: $ 

The contents of this box are for testing purposes. This box will be removed when the form goes live.
Full-Time Employees
Part-Time Employees
Hotel/Motel Rooms
Restaurant Seats
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
AdditionalCategories
Additional Categories Cost
NumberOfAdditionalCategories
additionalItem1Cost
Annual Dues (charged to card)
Tax (charged to card)
Fee (charged to card)
tempValueForDropDown1
Additional Directory Categories
  • Primary Directory listing is complimentary
  • Up to two additional Directory listings are complimentary
  • After two, additional Directory listings are $35 each
**Hold CTRL on your keyboard to select multiple categories**
Number of Locations ($35/add. location):  
Enhanced Membership ($50):
$ 
$ 
*
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.
Credit Card Information
Credit Card Type *
Credit Card Number * 
Name On Card
Security Code
Valid Through
Credit Card Address 1
Credit Card City
Credit Card State
Credit Card Zip
Credit Card Phone Number
Credit Card Email Address
Please click submit only one time.  The transaction may take several seconds.