Directory Listing
Business Name (appears in publications): ________________________________________________________
Business Phone #: ______-_______-______________ Business Fax #: _______-_______-______________
Email address:________________________________ Website:____________________________________
Directory Listing Address: ____________________________________________________________________
City/State/Zip
Mailing Address (if different): ___________________________________________________________________
City/State/Zip
Primary Rep (first/ last name): ______________________________________Phone________________________
Title: ________________________________ Email address: ________________________________________
Billing Address (if different): ____________________________________________________________________
City/State/Zip
Billing Rep (first/ last name): _____________________________________Phone__________________________
Title: ________________________________ Email address: ________________________________________
Preferred Method of Contact: • Email • Mail • Phone Preferred Method for Invoices: • Email • Mail
Brief Description of Business: _________________________________________________________________
Preferred Business Listing Category: ___________________________________________________________
Type of Membership: ___Business ___ Entrepreneurial ___Friend ___Non-Profit ___ Organization
___Place of Worship ___Home Based Business ___Government ___Associate
Number of Full Time Employees: ____Part Time: ____ Total Employees (each part time = ½ full time): _____
Number of Restaurant Seats: ______ Number of Units: _____ Year Business Established: __________
Business Tax Receipt License Number (required):
City#_____________________ County # ______________________ State #____________________
(you must furnish at least one of these licenses in order for your application to be processed.
north port businesses are required to have a north port business tax receipt.)
How did you hear about us?
__Chamber Member (name)______________________Chamber Staff/ Director (name)_______________
__Other (please explain): ______________________________________________
Photo Release:
I hereby release for good and valuable consideration, the receipt of which is hereby acknowledged, and I hereby irrevocably authorize
North Port Area Chamber of Commerce and their associates to use photographs of me and/or my property and authorize them and
their assignees, licensees, legal representatives and transferees to use and publish (with or without my name, company name, or with a
fictitious name) photographs, pictures, portraits or images herein described in any and all forms of media and in all manners including
composite images or distorted representations, for the purposes of publicity, illustration, commercial art, advertising, publishing
(including publishing in electronic form, on CDs, or internet websites) for any product or services, or other lawful uses as may be
determined by the photographer or studio representing North Port Area Chamber of Commerce. I further waive any and all rights to
review or approve any uses of the images, any written copy, or finished product. I am of full legal age and have read and fully
understand the terms of this release.
_____________________________________________________ ____/____/_____
SIGNATURE DATE
I understand that by providing a mailing address, telephone & fax number, I hereby consent to receive any and all communications sent
by or on behalf of the North Port Area Chamber of Commerce via regular mail, e-mail, telephone or fax. I understand that if any
of the above information changes, it is my responsibility to notify the Chamber so that my information can be updated in the system.
Annual Membership Dues: $______
Administrative Fee: $ 25.00
Total Amount: $______
Credit Card # ___________________________________________________
(All Major Credit Cards Accepted)
Exp: ____/____ CVV Code (on back of card) ______ Zipcode___________
82 www.NorthPortAreaChamber.com
080919