Name of Firm*

Contact Name & Title*

Street Address/PO Box*

City, State, Zip*

Phone Number*

Fax Number

Email Address

Website Address

Mailing or Billing Addresss (If Different.)

Owner/Manager Name & Title

Type of Business*

Please tell us who recommended Chamber Membership to you.

Chamber Membership Investment*

$330. (Minimum Investment - Up to 5 Employees.)   $330. PLUS $10. Per Each Additional Employee (Over 5 Employees).   Financial Insitutions - $28. Per Each Million in Deposits. (Minimum - $330.)   Professionals - $330. First Professional. $100. Each Additional Partner.

Number of Employees*

Applicant Estimated Investment Total*

Investment Method of Payment*

Check - Payment should be mailed to Chamber of Commerce 400 E. Church Street, Elmira, NY 14901.    Credit Card - Please contact the Chamber offices to relay credit information; phone 607.734.5137.