Items marked by (*) are required.

Company Information
Company Name: (*)
Your Name: (*)
Company Address: (*)
City: (*)	State: (*)
Zip: (*)
Phone: (*)
Fax:
E-mail Address: (*)
Web Site Address:
Mailing Address if different
Mailing Address:
City:	State:
Zip:
Permissions
May we list your membership information on the Chamber's Internet site? Yes No (*)
May we hyperlink your Internet site with the Chamber's site? Yes No (*)
Do you wish to receive Chamber related information via FAX? Yes No (*)
Demographic Questions
Company Product or Service: (*)
Number of Employees: (*)
Company Representative to the Chamber: (*)
Representative's Phone:
Representative's Email:
Alternate Representative:
How were you referred to the Chamber?

Membership Investment Schedule (Plus one time processing fee of $40)
1-5 Employees	$360.00	200-299 Employees	$1,240.00
6-10 Employees	$440.00	300-399 Employees	$1,450.00
11-29 Employees	$600.00	400-499 Employees	$1,675.00
30-99 Employees	$825.00	500+ Employees...add $1.00 per employee
100-199 Employees	$990.00
You will be charged for the total amount of your membership dues.

Membership Dues
Membership Dues: Enter from schedule above
Processing Fee:
Total:
Credit Card Information
If you wish to pay by check, please print the form and send payment to: Tom Brennan, Membership Director Costa Mesa Chamber of Commerce 1700 Adams Avenue, #101 Costa Mesa, CA 92626

First Name: (*)
Last Name: (*)
Address: (*)
City: (*)	State: (*)
Zip:(*)
Credit Card Type: (*)	Visa Master Card American Express
Card Number: (*)
Expiration Date:(*)	Month: Year :