Member Application

Thank you for your interest in membership to the Columbus Area Chamber of Commerce. Please fill out the application below, keeping in mind, this information is what will show online once you are an active member. If you have any questions, please call 812.379.4457. If you would like to join the Columbus Young Professionals, please visit the CYP page under the Community tab.

Business Information

Company Name: *

Leave Blank:

Phone: *

Website: *

Email: *

Business Description (200 char max):

Directory Category:

Employees: *

Full-time Part-time

Business Keywords (enter a space between words):

Comments / Questions:

Professional Employee:

Location:

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:

Social Networking:

LinkedIn Facebook Twitter You Tube

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Email: *

Contact Preference:

Email Phone

Password: *

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: *

Email: *

Contact Preference:

Email Phone

Password: *

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Payment Option:

Bill me

Print Application

Member Application

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