Member - The Brillion Area Chamber of Commerce

Member Application

If you are applying as a new member please complete this form. After you complete "Step 1" on the form click on the "Step 2" button, etc. There are 5 steps to complete your form. Once you complete Step 5, click on "I am a Robot" to lead you to a secure payment page. Thank you for choosing the Brillion area Chamber of Commerce!!

Step 1: Member Info

Step 2: Additional Info

Step 3: Primary Contact

Step 4: Billing Contact

Step 5: Membership Options

Step 1:

Member Info

Company Name *
Please add your company name.

Leave Blank

Phone *
Please add your company phone number.

Website

Email *
Please add a valid email.

Physical Address

Address line 1 *
Please add your address.

Address line 2

Country *
Please add your country.

City *
Please add your City.

State *
Please add your State.

State *
Please add your State.

State *
Please add your State.

Postal Code *
Please add your Postal Code.

Mailing Address

Same as physical address

Address line 1 *
Please add your address.

Address line 2

Country *
Please add your country.

City *
Please add your City.

State *
Please add your State.

State *
Please add your State.

State *
Please add your State.

Postal Code *
Please add your Postal Code.

Social Network Addresses

LinkedIn

Facebook

Step 2:

Additional Info

Business Description (200 char max) *
Please add your company description.

Business Keywords * (enter a space between words)
Please add your business keywords.

Directory Category

Full-time Employees *
Please add your number of full-time employees.

Part-time Employees *
Please add your number of part-time employees.

Do You Accept Chamber Bucks *
Looks good!

Chamber Bucks Sponsor *
Looks good!

Advantage Card Discount Offer *
Looks good!

Chamber Sponsorship Information *
Looks good!

Step 3:

Primary Contact

First Name *
Please add your first name.

Last Name *
Please add your last name.

Title

Phone *
Please add your phone number.

Cell Phone

Fax

Email *
Please add a valid email.

Contact Preference

Email

Phone

Address

Same as Address in Step 1

Address line 1 *
Please add your address.

Address line 2

Country *
Please add your country.

City *
Please add your City.

State *
Please add your State.

State *
Please add your State.

State *
Please add your State.

Postal Code *
Please add your Postal Code.

Social Network Addresses

LinkedIn

Facebook

Create Account

This Login is already in use

Login *
Please add your login username.

Password *
Please add your login password.

Step 4:

Billing Contact

Same as Primary Contact

First Name *
Please add your first name.

Last Name *
Please add your last name.

Title

Phone *
Please add your phone number.

Cell Phone

Fax

Email *
Please add a valid email.

Contact Preference

Email

Phone

Address

Same as Primary Contact Address

Address line 1 *
Please add your address.

Address line 2

Country *
Please add your country.

City *
Please add your City.

State *
Please add your State.

State *
Please add your State.

State *
Please add your State.

Postal Code *
Please add your Postal Code.

Social Network Addresses

LinkedIn

Facebook

Create Account

This Login is already in use

Login *
Please add your login username.

Password *
Please add your login password.

Step 5:

Membership Package

Please select a Membership Package

Private Citizen $ 50

Non-Profit $ 50

1-9 Employees $ 150

10-99 Employees $ 225

100+ Employees $ 1,000

Additional Options:

Chamberbucks Sponsorship $200 one time
If you would like your logo added to next years Chamberbucks certificates please donate $200 to support Chamberbucks and shopping local.

Comments/Questions

Payment Option

Bill Me

Charge my credit or debit card

Please complete the Captcha

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