2012 Membership Application Form

Business Name: _________________________________________________
Mailing Address: ________________________________________________
City: _____________________________ Postal code: __________________
Location (if different): ____________________________________________
Phone: ________________________ Fax: ___________________________
 E-mail: _______________________________________________________
Website: _____________________________________________________
Contact Person: __________________________________________
Brief description of business for new member intro:______________________
_______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Date Joined: ____________________________________________________
Applicant’s Signature: _____________________________________________
How did you hear about the Chamber? ________________________________
Number of Full-time Employees (part-time employees add up to full-time employees):
_________________
Membership Category: 0 to 5 employees____6 to 20 employees_____ 21 plus employees_____ Associate or Non-Profit ____
________________________________________________________________
Payment Options: Chamber membership is a tax-deductible business expense.
Paid by cheque - amount enclosed________
Paid by VISA/MasterCard/American Express: _____________________________
Card Number __________________________________________ Exp:________
Make cheques payable to: South Cowichan Chamber of Commerce

Membership Fees – January 1st - December 31st
Membership Category Fee +HST Total
Owner-Operated 1-5 employees $ 180.00 + $ 21.60 $201.60
Small Business 6-20 employees $ 340.00  + 40.80 $380.80
Large Business 21 Plus employees $ 450.00 + 54.00 $490.80
Associate & Non Profit $ 180.00 + 21.60 $201.60

NOTE: # part-time employees adds up to full-time employees

Please provide information on the following benefits for Chamber members:
Group Health Insurance _____
VISA/MasterCard/Interac discounts _____
PayWorks Payroll______
ShawSabey _____
Fuel discounts  _____
Constant Contact ______

Please contact me about…
Advertising in:
Visitor Info Map ___
SCCC Website ___
Other advertising opportunities _____
Thrifty Smile Card Program Fundraising _____
Volunteering: ___ for an event ___ on a committee _____
Donating to the Visitor Info Booth in Mill Bay _____