Member Application

Thank you for your interest in the Fayette County Chamber of Commerce! Please complete the application below and submit. A member o the Chamber will contact you shortly to find out how we can help you with the challenges or interest you have in the community.

Business Information

Company Name: *

Leave Blank:

Phone: *

Website:

Email:

Business Description (200 char max): *

Directory Category:

Employees:

Full-time Part-time

Business Keywords (enter a space between words): *

Comments / Questions:

Physical Address

Line 1:

Line 2:

City:

State:

Postal Code:

Country:

Mailing Address

Same as physical address

Line 1:

Line 2:

City:

State:

Postal Code:

Country:

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone:

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1:

Line 2

City:

State:

Postal Code:

Country:

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone:

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1:

Line 2

City:

State:

Postal Code:

Country:

Membership Options

Payment Option:

Bill me Charge my credit or debit card

Print Application

Printed courtesy of fayetteinchamber.com/ – Contact the Fayette County Chamber of Commerce for more information.
504 N. Central Avenue, Connersville, IN 47331 – (765) 825-2561 – [email protected]