Kendallville Chamber Application Form

    **** Required ****

Company Name: *

Primary Contact Information:  * 

Human Resource Contact Information:      

Mailing Address:  * 

                   CITY:  *  STATE:         *  ZIP CODE:       *

Physical Address (if different as above):   

                   CITY: STATE: ZIP CODE:      

Phone Number:  *

Fax Number: 

Email:  *

Website: 

Product/Specialty : 

Categories

Retail    Professional    Service    Industrial    Individual    Home-Based   
Restaurant    Associate   Club/Organization

Number of Employees:         Square footage of Building:      
Year Established: 

   BILL ME

   CREDIT CARD

                                 CREDIT CARD #:          SECURITY CODE:       

                                   EXP MONTH:  - 01 02 03 04 05 06 07 08 09 10 11 12     EXP YEAR: - 2008 2009 2010 2011 2012 2013 2014