*Company Name:

*E-mail Address:

Street Address:

City:

State:

Zip Code:

PRIMARY CONTACT

*Name:

Title:

SECONDARY CONTACT

Name:

Title:

E-mail:

# of Full-Time Employees:

# of Part-Time Employees:

Primary Phone Number:

Secondary Phone Number:

Fax Number:

Website Address:

Business Category:

Business Description:
(25 words or less)

Business Councils:

Please check the Business Council(s) on which you and/or your representative wish to participate
Banking & Financial Services
Business & Professional Services
Construction & Utilities
Education & Government
Government Contracting Business Council
Health & Wellness Business Council
Hispanic
Not-for-Profit
Retail
Technology & Manufacturing
Tourism, Hospitality, Entertainment & The Arts

Committees:

Please check the committee(s) in which you and/or your representative wish to participate
Ambassadors
Business Growth & Development Commitee
Communications Commitee
Community Development Commitee
Programs Committee
Public Policy Committee

Please indicate how you learned about the Region's Chamber:

Newspaper Article
Newspaper Ad
Website
Referred by Chamber Member
Other

Please enter name of newspaper, website, Chamber Member, or describe other:

Payment Method:

Credit card or other electronic payment: I will select the
      "Buy Now" option that will appear once I have submitted
      this form.
I will send in my dues by check to:

      Prince William Regional
      Chamber of Commerce
      4320 Ridgewood Center Drive
      Prince William, VA 22192  

(Questions, call the Chamber office at 703-590-5000 x105.)

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