Membership Application
Name of Firm
_____________________________________________________________
Address __________________________________________________________________
Town/City ________________________________________ Zip Code
_______________
Telephone ___________________ FAX _____________ E-mail
_____________________
Mailing Address (if different from above)
_______________________________________
Description of business or profession
___________________________________________
___________________________________________________________________________
President or Principal Officer _______________________________________________
Name of Executive to Contact _______________________________________________
Number of Years in Business ________
Average Number of Full-time Employees, including principals
_________
Number of branches included in membership _________
Is your firm a member of a national corporation? __________
Is your firm interested in health insurance through Chamber
membership? _________
Annual Fee Membership Schedule: (check one)
|
Churches/Nonprofit
Clubs
|
$50.00
|
_____
|
|
Owner/Operator
|
$95.00
|
_____
|
|
2 - 4
Employees
|
$100.00
|
_____
|
|
5 - 10
Employees
|
$115.00
|
_____
|
|
11 -
15 Employees
|
$145.00
|
_____
|
|
16 Ð25
Employees
|
$175.00
|
_____
|
|
26 -
100 Employees
|
$230.00
|
_____
|
|
101 -
200 Employees
|
$290.00
|
_____
|
|
201 -
300 Employees
|
$345.00
|
_____
|
|
300 +
Employees
|
Negotiable
|
_____
|
Utility
|
$250.00
|
|
Sign and Date this application,
and return it, with the fee to
Post Office Box 585, Wakefield, MA 01880
Signature ________________________________________ Date
_________________
