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Please fill out the form as completely as possible. Contact information is very important should we need to check with you about any submitted information. Pricing is based on the number of employees, so please do not forget to complete that section. Thank you for partnering with the Powhatan Chamber.
 

Member Application:

* Company Name:  
* Phone:  
Website:
* Email:
* Business Description (200 char max)
 
* Physical Address:  
* City/State/ZIP:  
Country:
 
Mailing Address: Same as physical address
City/State/ZIP:
Country:
 
Business Category:
Employees: Full-time:      Part-time: 
Comments/Questions:
 
 

Primary Contact Information:

* Name (First / Last):  /   
Title:  
* Phone:  
Fax:
* Email:  
Contact Preference: Email  Phone
 
Social Networking: LinkedIn:
Facebook:
 
Address: Same as Company Address
City/State/ZIP:
Country:
 
 

Billing Contact Information:
Same as Primary Contact
* Name (First / Last):  /   
Title:  
* Phone:  
Fax:
* Email:  
Contact Preference: Email  Phone
 
Social Networking: LinkedIn:
Facebook:
 
Address: Same as Company Address
City/State/ZIP:
Country:
 
 
Membership Package:
Memb Level 1: $100.00
1-3 employees
Memb Level 2: $125.00
4-10 employees
Memb Level 3: $175.00
11-25 employees
Memb Level 4: $225.00
26-50 employees
Memb Level 5: $250.00
50 +
Memb Level 6: $50.00
Not for Profit
Memb Level 7: $50.00
Individual Non Business Listing
Payment Option:
Bill me
Charge my credit card
 
 
Submit Application:
Enter the CAPTCHA words, then press the Submit Application button.
  Submit Application Print Application
 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

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