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*Required Field  
Primary Contact First Name:*
Primary Contact Last Name:*
 
Billing Information: (USE THE INFORMATION ON FILE WITH THE CREDIT CARD YOU ARE USING)
 
Business Name:*
Billing Mailing Address:*
Billing City:*
Billing State:*
Billing Zip Code:*
 
Physical Address:
Physical City:
State:
Zip Code: 
Primary Phone:*
Fax:
Cell Phone:
Contact Preference:  Email      Fax      Phone    
E-mail:*
Website:
Number of Employees:* Full-Time   Part-Time 
Type of Business:*
How long has the company been in business?*
Business Description:
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Membership:


  Number of Rooms(For Type C Membership):
Sponsored By:
Comments:
 
Payment Information:
 
Name on Card:*
CC Type:*
CC Number:*
CVV(II) Code:* (where to look)
Expiration Date:* /
 
  Additional $50.00 administration fee is applied
 
 

 

 

 

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