Ballard
County Chamber of Commerce
MEMBERSHIP
APPLICATION
547 West Kentucky Drive
LaCenter, KY 42056
(270)665-8277
· E-mail: bcchamberinfo@brtc.net
Company/Individual name:__________________________________________________________
Contact person:__________________________________________________________________
Contact person title:______________________________________________________________
Street Address:______________________________ Zip:_________________________________
P.O. Box:______________________________________________________________________
City:______________________________________
Zip:________________________________
State:_________________________________________________________________________
Web address:_______________________________
E-mail address:_______________________
Telephone:_________________________________
Fax:________________________________
Date established:_____________________________ Year incorporated:_____________________
Number of full-time employees:____________ Number of part-time employees:________________
Business category (1)_____________________________________________________________
(2)_______________________________________
(3)_________________________________
Description of company and its services (25 words or
less, please):___________________________
______________________________________________________________________________
______________________________________________________________________________
Membership investment schedule (two part-time employees is equivalent to one full-time employee):
Individual, club, organization: $ 50 Financial institutions $500
1 to 5 employees $100 utilities and major
6-10 $150 corporations
11 or more employees $300 Cities and towns $200
Professionals (doctors, lawyers, $150
insurance or real estate Out-of-county entities $100
agents, etc.)
Membership rate:___________________________________________________________________________
New member signature:______________________________ Date:____________________________________
Membership recruiter
signature:________________________________________________________________
(Please print names clearly beside signature)