Member Application

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.

Business Information

Company Name: *

Leave Blank:

Phone: *

Website:

Email: *

Business Description (200 char max): *

Directory Category:

Employees:

Full-time Part-time

Comments / Questions:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1:

Line 2:

City:

State:

Postal Code:

Country:

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1:

Line 2

City:

State:

Postal Code:

Country:

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1:

Line 2

City:

State:

Postal Code:

Country:

Membership Options

Membership Package: *

Memb Level 1: $125.00
1-3 employees Memb Level 2: $150.00
4-10 employees Memb Level 3: $200.00
11-25 employees Memb Level 4: $300.00
26-50 employees Memb Level 5: $450.00
50 + Memb Level 6: $75.00
Not for Profit Memb Level 7: $75.00
Individual Non Business Listing

Payment Option:

Bill me Charge my credit or debit card

Print Application