2012 Membership Application

Member Information

• Name of Organization/Business/Public Entity or Individual
• -------------------------------------------------------------------------------
• Street or P.O. Box Address
• ------------------------------------------------------------------------------
• City, State and Zip
• ------------------------------------------------------------------------------
• Billing Address
• ------------------------------------------------------------------------------
• Type of Business
• -----------------------------------------------------------------------------
• Representative to Chamber of Commerce
• ------------------------------------------------------------------------------
• Telephone             Fax/Number                   Home Phone
• ------------------------------------------------------------------------------
• E-Mail Address                                 Website
• ------------------------------------------------------------------------------

----Need a COC Logo          -----Need a year Strip        

-----Receive newsletter electronically       -----Advertise on Website   

-----Need an Invoice     -----Need a Member Certificate 

Membership  Annual Dues

• Membership Annual Dues- Due, January 5 ,2012
• Business
• 1-5 Employees $95.00
• 6-25 Employees $100.00
• 25+ Employees $105.00
• Public Entity------------------------$58.00
• Individual---------------------------$40.00
• Service Organization----------------$29.00
• Auxiliary----------------------------$10.00..with full member
• $10.00 late fee after due date for everyone

Return this completed page with a check payable to:

• Bellbrook-Sugarcreek Area ( BSACoC)
• Chamber of Commerce
• 64 West Franklin St.
• Bellbrook, Ohio 45305

Check #________________        Amount_________________

Date___________________         Received by_____________

Please Volunteer, Your Chamber needs your help. Please indicate the committees in which you are interested.

---Business or Health Expo    

   ---Garage Sale   ---Golf Outing   ---Halloween in the Park

---Membership   ---Newsletter   ---Office Assistance   ---Scholarship

---Sugar Maple Festival     ---Networking Events