Membership Application
Last Name : Middle Name : First Name :
     
Company : Title : Industry :
     
Company Address :
Phone : Fax :
 
Email : Website :
 
*Please check the appropriate box of the membership level for which you are applying:
 
Membership Level: Dues:
Large Company $1000 (Annual)
Medium Sized Company $5,00 (Annual)
Small Company $250 (Annual)
Entrepreneur $500 (Annual)
Student $50 (Annual)
Total Amount Due : _________________
 
*Full membership offers members use of all facilities and resources of the Chamber, as well as invitations to general meetings and to all Chamber events. All membership fees are nontransferable.
 
Payment Information
Method of Payment :  
Check Check #: ________________________________
* All Checks should be made payable to the US India Chamber of Commerce Midwest.
  Master Card     Visa     AmEx  
Card #: _____________ Exp. Date : ______________________
Signature : ____________________________________________
I have completed this application for membership to the U.S. India Chamber of Commerce Midwest, Inc and hereby certify that the information contained within is true and accurate to the best of my knowledge.
 
Please mail completed forms with payment to the following address, care of Ms. Emily Brinkmoeller
(usindia.chamber@gmail.com)