*Firm Name:
|
Business Established:
|
| Ownership (check all that apply): |
Female
Male
Caucasion
African American
Hispanic
Asian
Other
|
| Maling Address |
*Address:
|
*City:
|
*State:
|
*Zip:
|
*Key Contact:
|
Title:
|
| Physical Address |
Address:
|
City:
|
State:
|
Zip:
|
*E-mail:
|
Internet Address:
|
*Phone Number:
|
Number of Employees:
|
*Business Classification:
|
Financial Institution
Total Annual Deposits |
Describe Goods or Services:
|
Hotel/Motel
Number of Rooms
Apartments
Number of Units
|
| Annual Investment Schedule |
| Employees |
Over 1000 Annual Dues |
| 1-10 |
$300 |
| 11-20 |
$400 |
| 21-50 |
$500 |
| 51-100 |
$600 |
| 101-200 |
$700 |
| 201-1000 |
Employee count rounded up to the nearest hundred, additional $100 per hundred over 200 |
| Over 1000 |
$2,500 |
|
Investment Worksheet:
*Annual Dues:
Upgrade to Gold x 50%
Upgrade to Platinum x 200%
One-time Administrative Fee:
$25 (non-refundable)
*TOTAL INITIAL INVESTMENT:
|
|
