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Organization Information (to be displayed online)

Organization Name

Address 1

Address 2

City

State

Zip

Phone

Fax

Website

Main Contact

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First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

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

Copy from Main Contact

Address 1

Address 2

City

State

Zip

Mailing Address

Copy from Main Contact

Address 1

Address 2

City

State

Zip

Additional Information

Referred By

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What is your reason for joining?

Would you be interested in Community Impact Partnership for your business in the future?

Please have someone contact me regarding

Business Advocacy
Business Visibility
Business Connections
Community Involvement
Young Professionals Organization
Volunteer Opportunities

Membership Investment

Investment Level

Primary Directory Category

Additional Directory Categories

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Secondary categories may be subject to additional fees

Annual Membership Investment

Total

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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Upcoming Events

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Upcoming Events

Thank you Legacy Partners

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