Membership ApplicationPost Office Box 2008 Anderson, IN 46016 Open Form MEMBERSHIP APPLICATION Name * First Name Last Name Title Company Address City State * Zip Phone * (###) ### #### Office Phone Email * Business Category Description Company's activities 50 words or less. Date Business was established. Which of the following business certification do you hold? Minority Business Enterprise (MBE) Women Business Enterprise (WMBE) Disable Veteran Handicapped N/A 2024 Annual Membership Assessment * January 1, 2024 through December 31, 2024 Business $100.00 Nonprofit $50.00 Associate Member $50.00 Please Check: * Are you a returning member or New Member Renewal ELECTRONIC SIGNATURE * DATE * Membership Payment Acknowledgment * By checking this box, I acknowledge that: A payment is required to complete and secure my membership with the Anderson Madison County Black Chamber of Commerce, Inc. The total membership payment will be displayed and processed after submitting this form. My membership is not considered active until the full payment is received and processed. I understand that submission of this form does not guarantee membership until payment is completed. I Acknowledge Thank you for joining the Anderson Madison County Black Chamber of Commerce, Inc.! Please submit your membership assessment before you go!