Page 23 - midJersey Business - March 2015
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MEMBERSHIP APPLICATION
1A Quakerbridge Plaza Drive • Suite 2 • Hamilton, NJ 08619
P609.689.9960 F609.586.9989
www.MIDJerseyChamber.org
Company Information
Business Name _________________________________________________________________ Date _________________
Mailing Address _______________________________________________________________________________________
City _____________________________________________________ State ___________ ZIP _______________________
Physical Address ______________________________________________________________________________________
City _____________________________________________________ State ___________ ZIP _______________________
Main Phone _______________________________ Main E-mail_________________________________________________
Main Website ___________________________________________ Main Fax _____________________________________
_
Type of Business __________________________________________________ How many years in business _____________
Employee/Contact Information
Number of Employees: Full Time: ______________ Part Time: ______________
Primary Contact _____________________________________________ Title _____________________________________
_
E-mail _____________________________________________________ Phone ___________________________________
_
Human Resource Contact ________________________________________ Title __________________________________
E-mail _____________________________________________________ Phone ___________________________________
_
Other Contact ______________________________________________ Title ______________________________________
E-mail _____________________________________________________ Phone ___________________________________
_
Howdidyouhearaboutus?Event Website SocialMedia Newspaper Referredby___________________________ _
Questions? Contact our membership Department 609.689.9960, ext. 21
Method of Payment
Check MasterCard VISA AMEX Discover Amount $__________________________________ _
Card Number ____________________________________________________ Exp. ______________ SID ______________ _
Cardholder Name _____________________________________________________________________________________ _
Billing address of Card Holder ____________________________________________________________________________
Signature ___________________________________________________________________ Date ____________________
