Member

Business Information

Company Name: *

Leave Blank:

Phone: *

Website:

Email: *

Business Description (500 char max):

Directory Category: *

Employees: *

Full-time Part-time

Business Keywords (enter a space between words):

Comments / Questions:

About Us:

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

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email:

Contact Preference:

Email Phone

Login:

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: *

Cell Phone:

Fax:

Email:

Contact Preference:

Email Phone

Login:

Password:

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Retired Partner: $95.00
Community Partner: $125.00
Non-Profit, Charitable, and Civic Organizations (including Churches) Business Partner 0-50 Employees: $250.00
Business Partner 51-200 Employees: $600.00
Business Partner 201+ Employees: $1,200.00
Financial Institutions: $1,200.00
Economic Partner: $2,500.00
President's Circle: $5,000.00

Additional Fees:

New Member : $25.00
- Processing Fee

Additional Opportunities:

We will contact you with additional information.

Education Donation : $10.00
to the Lake Wales Area Foundation Additional : $25.00
- Extra Category Listing

Payment Option:

Bill me

Member Application

Mailing Address

Address

Address