TRI-STATE HISPANIC CHAMBER OF COMMERCE
MEMBERSHIP APPLICATION
402 Main Street
Joplin, Missouri 64801

Phone: (417) 625-3250

MEMBERSHIP INFORMATION:
o NEW o RENEWAL

Name: _____________________________________________ Title: _____________________________

Company/Organization: __________________________________________ Year Established: _________

Address: ________________________________ City: ____________________ State: _____ Zip: _______

Phone: _______________________ Fax: _________________ Email Address: ______________________

Type of Business:
(Will be used for Chamber directory): ___________________________ Website: _____________________

Certifications: ______________________________________________________________________

Is your company Hispanic owned and operated? o Yes o No

Is your company Woman owned? o Yes o No

ANNUAL MEMBERSHIP INVESTMENT

Business Level:

o 1-4 Employees $200.00

o 5-10 Employees $250.00

o 11-20 Employees $350.00

o 21-50 Employees $525.00

o 51-100 Employees $600.00

o 101+ Employees $750.00

Individual Level:

o Retiree. $75.00

o Student $50.00

o Non-Profit Organization $300.00

PAYMENT METHOD:

o Send Invoice o MasterCard o VISA o CASH
o Check Enclosed (Payable to: Hispanic Chamber of Commerce)

Credit Card Number: ___________________________________________ Exp. Date: ______/_______


X______________________________________________
Authorized Signature

FOR OFFICE USE ONLY:

Received on: ___________________________________, 200___ Approved on: _____________________


Sponsored By: _______________________________________________________

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