MEMBERSHIP APPLICATION M AX I M I Z E O U R VA L U E TO YOU R OR GAN I ZATI ON Please complete and return the following information. Your response will enable us to activate your company’s official membership. The Kentucky Chamber will use this data for official purposes only.
K EY I N F O R MATI O N Contact Name
Areas of
I NTE R E S T
Title
Organization
Address
City/State
Phone
Fax
Zip Code
Human Resources
Small Business
Energy/Environment
Political Education
Tax & Fiscal Policy
Education
Economic Development
Member Savings
Health Care
Workforce
Why are you joining the K E N TU CKY CHAM B E R
Website
YES Number of Employees
NO
Advocacy. I want to ensure my company’s voice is heard in Frankfort and Washington D.C.
Member of Local Chamber? Name of Local Chamber
Member Savings Opportunities. Check all that apply:
AD D IT I O N AL C O N TACT I N F OR MATI ON
Anthem BlueCross BlueShield Delta Dental Kentucky Employers’ Mutual Insurance
Government/Public Affairs (Name, Title)
Human Resources (Name, Title)
Lifestyle Health Plans Staples UPS Freight Shipping
Saftey/Environmental (Name, Title)
Marketing (Name, Title)
Valvoline
I N V E STM E N T Please calculate your investment based on the number of employees in Kentucky. Two part-time employees equal one full-time employee. Stakeholders
I understand that by providing the contact information above, on behalf of the organization specified above, I am authorized to and hereby consent for the organization to receive faxes and e-mails sent by or on behalf of the Kentucky Chamber of Commerce.
$595 + $8 per employee
Key Investors Cornerstone Members* Equity Partners Trustees Presidential Advisors Chairman’s Circle Commonwealth Partners
$1,000 $2,500 $5,000 $10,000 $25,000 $50,000
Number of Employees (if over 1)** (**If your company has more than 100 employees, contact the membership department for your investment amount.)
Annual Dues
(*Cornerstone Member Level exclusively for companies with fewer than 50 employees)
Total Investment:
Contact your legislator at 800-372-7181.
(If applying for Stakeholder Level, add $8 per employee)
Signature: Home Address Zip Code
PAYM E NT
(needed to send information related to your legislative district)
Pay by check
Invoice Me
Yes, I understand that I will need to contact my legislator on behalf of Kentucky businesses when the Chamber issues an Action Alert.
Pay by credit card
VISA
Mastercard
American Express
$ Amount
Check No.
Card Number
Exp. Date
Security Code
kychamber.com | (502) 695-4700 | @KyChamber | 464 Chenault Road, Frankfort, KY 40601