Page 21 - midJersey Business - January 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____________________________
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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 ____________________
january 2015 19
