Application | Waterbury Regional Chamber | Waterbury, CT

Application

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Organization Information (to be displayed online)

Firm

Address 1

Address 2

City

State

Zip

Phone

Cell Phone

Fax

Website

Email

Primary Contact

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First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

Cell Phone

Email

Additional Contacts

Contact 1

First Name

Last Name

Title

Email Address

Contact 2

First Name

Last Name

Title

Email Address

Contact 3

First Name

Last Name

Title

Email Address

Contact 4

First Name

Last Name

Title

Email Address

Contact 5

First Name

Last Name

Title

Email Address

Contact 6

First Name

Last Name

Title

Email Address

Contact 7

First Name

Last Name

Title

Email Address

Contact 8

First Name

Last Name

Title

Email Address

Contact 9

First Name

Last Name

Title

Email Address

Contact 10

First Name

Last Name

Title

Email Address

Add/Remove Contacts

Billing Address (if different)

Address 1

Address 2

City

State

Zip

Mailing Address (if different)

Address 1

Address 2

City

State

Zip

Additional Information

Membership Investment

Chamber Affiliation

Primary Directory Category

Additional Directory Categories

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Secondary categories may be subject to additional fees

Keywords (to help users find you in the Directory Search)

Products and Services (to be added to enhance your listing)

Number of Full Time Employees

Number of Part Time Employees

Health Care Opt-in ($50)

I would like to join the Young Professionals of Waterbury Region.

Number of Young Professionals

Annual Membership Investment

Additional Categories Cost

Young Professionals Fee

One-Time Application Fee

Total

Membership is automatically renewed annually unless written notification is received.

Young Professionals Membership Fee

Tax

Additional Items

Number of Rooms

Number of Seats

Number of Associates

Number of Locations

Millions in Assets

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Full-Time Employees

Part-Time Employees

Hotel/Motel Rooms

Restaurant Seats

Additional Associates

Additional Associates Cost

Additional Locations

Additional Locations Cost

Assets

Assets Cost

Additional Categories

Number Of Additional Categories

Additional Categories Cost

Additional Item 2 Cost

Additional Item 3 Cost

Additional Item 4 Cost

Additional Item 5 Cost

Additional Item 6 Cost

Additional Item 7 Cost

Additional Item 8 Cost

Additional Item 9 Cost

Additional Item 10 Cost

Annual Dues (charged to card)

Revenue Item

Tax (charged to card)

Fee (charged to card)

Temp Value For DropDown 1

MembershipType

Additional Item 2

Additional Item 3

Additional Item 4

Additional Item 5

Additional Item 6

Additional Item 7

Additional Item 8

Additional Item 9

Additional Item 10

Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Credit Card Information

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Credit Card Type MastercardVisaDiscoverAmex

Credit Card Number

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

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