Name of Applicant *

Date*

Job Title *

Business Name *

Fiscal Manager Name * (for invoicing)

Fiscal Manager Email *

Accounts Payable Name *

Accounts Payable Email *

Address*

City*

P.O. Box

State*

Zip Code*

Office Phone *

Cell Phone

Email*

Primary type of work performed

Years in business

Number of Employees*

Annual Sales

NAICS Code*

Name

Email

Name

Email

Regular Member - $2,000.00 per year (More than 250 employees)Regular Member - $1,000 per year (More than 100 employees)Regular Member - $750 per year (More than 25 employees)Regular Member - $500 per year (25 employees and fewer)Associate Member - $500 per year (Non-manufacturing business and organizations)Workforce Development - $1,500 per yearEducation Partner - $500 per yearCommunity Partner - $250 per yearIndividual Member - $100 per year - (Retiree or Individual)