Company Name: 

Contact Name: 

Address: 

Address: 

City:     State: 

Zip code: 

Telephone #: 

Fax #: 

Email Address: 

Type of Business: 

Number of Employees: 

Do you have a website?  Yes No

Would you like your website linked with ours?  Yes No

In consideration of the satisfaction and value received from joining others in serving the best interests of the community, I hereby pledge my investment to the Southern Wayne Regional Chamber of Commerce.

  Thank you.