Membership Application

Please complete the information below. The investment schedule for a Business Membership is based on business size and calculated by either the number of full-time employees in a business (2 part-time = 1 full-time), or the type of business/organization. There is separate pricing for Individuals, Financial Institutions, Real Estate Companies, Hotels, and Nonprofits (see Membership Investment section).

For a printed application, please email Member Services at memberservices@rogerslowell.com or call 479-636-1240.

Organization Information

Organization Name

Physical Address 1

Physical Address 2

City

State

Zip Code

Phone Number

Fax Number

Website

Do you want your physical address listed in web and print directories?

Yes

Main Contact

Copy from Organization-Information

First Name

Last Name

Title

Address 1

Address 2

City

State

Zip Code

Phone Number

Cell Phone Number

Additional Representatives

Add/Remove Contacts

Contact 1

First Name

Last Name

Title

Email Address

Phone Number

Cell Phone Number

Contact 2

First Name

Last Name

Title

Email Address

Phone Number

Cell Phone Number

Billing Address (if different)

Address 1

Address 2

City

State

Zip

Phone Number

Mailing Address (if different)

Address 1

Address 2

City

State

Zip

Additional Information

Membership Investment

Membership Type

Number of Full Time Employees

Number of Part Time Employees

Number of Rooms

Number of Agents

Million in Deposits ( ex for $1 million, enter 1 )

Additional Locations ($50 each)

Physical Address Additional Location 1

Address 1

Address 2

City

State

Zip Code

Physical Address Additional Location 2

Address 1

Address 2

City

State

Zip Code

Physical Address Additional Location 3

Address 1

Address 2

City

State

Zip Code

Physical Address Additional Location 4

Address 1

Address 2

City

State

Zip Code

Annual Membership Investment

Total

Membership shall be continuous unless cancelled in writing by the member. Dues to the Rogers Lowell Chamber are not deductible as a charitable contribution for income tax purposes but may be deductible as an ordinary and necessary business expense. A portion of dues (6%) however is not deductible as an ordinary and necessary business expense to the extent that the Chamber engages in state or federal lobbying.

Credit Card Information

Copy from Organization Information

Credit Card Type

Mastercard

Visa

Discover

Amex

Credit Card Number

Name on Card	Required
Security Code	Required
Valid Through
Address	Required
City	Required
State
Zip	Required
Phone	Required
Credit Card Email Address

Please click submit only one time. The transaction may take several seconds.

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Contact 1

Contact 2

Physical Address Additional Location 1

Physical Address Additional Location 2

Physical Address Additional Location 3

Physical Address Additional Location 4

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