Member Application

Business Information

Company Name: *

Phone: *

Website:

Email: *

Business Description (200 char max): *

Business Category: *

Employees:

Full-time Part-time

Business Keywords (enter a space between words):

Comments / Questions:

Hours of Operation:

Founding Year: Select mm/dd/yyyy

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Social Networking:

LinkedIn Facebook

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1:

Line 2

City:

State:

Postal Code:

Country:

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1:

Line 2

City:

State:

Postal Code:

Country:

Membership Options

Payment Option:

Bill me

In the effort to fight spam, please provide the answer to the following question.

What is the sum of 6 plus 9?: *

Print Application

Printed courtesy of www.sewardne.com/ – Contact the Seward County Chamber & Development Partnership for more information.
616 Bradford St., Seward, NE 68434 – (402) 643-4189 – [email protected]