Member

Step 1:

Member Info

Company Name *

Please add your company name.

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.

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.

Postal Code *

Please add your Postal Code.

Social Network Addresses

Facebook

Instagram

Twitter

Step 2:

Additional Info

Business Description (200 char max)

Business Keywords (enter a space between words)

Directory Category

Full-time Employees *

Please add your number of full-time employees.

Part-time Employees *

Please add your number of part-time employees.

Referred by

Why do you want to be a member?

Source - How did you hear about us?

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

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.

Postal Code *

Please add your Postal Code.

Facebook

Instagram

Twitter

Create Account

Password *

Please add your login password.

Step 4:

Billing Contact

Same as Primary Contact

First Name

Last Name

Title

Phone

Cell Phone

Fax

Contact Preference

Phone

Address

Address line 1

Address line 2

Country

City

State

Postal Code

Social Network Addresses

Create Account

Password

Step 5:

Comments/Questions

Payment Option

Bill Me

Charge my credit or debit card

Please complete the Captcha

Back Next Submit Application Print Application

Member Application

Step 1:

Member Info

Physical Address

Mailing Address

Social Network Addresses

Step 2:

Additional Info

Step 3:

Primary Contact

Address

Create Account

Step 4:

Billing Contact

Address

Social Network Addresses

Create Account

Step 5:

Payment Option

East Peoria Chamber of Commerce