MEMBERSHIP INFORMATION

Business Name:______________________________________________________________

Contact Name:_______________________________________________________________

Physical Address:____________________________________________________________

Mailing Address:______________________________________________________________

Telephone:___________________________ Fax:___________________________________

Email:_______________________________________________________________________

Web site:____________________________________________________________________   

Type of Membership:

_____Hometown Hero—Champion         $3200

_____Hometown Hero—Winner               $1750

_____Hometown Hero—Victor                 $1000

_____Hometown Hero—Star                   $750

_____Business Membership                   $200    

_____Multiple Business Member             $100  (same ownership, for each business thereafter)

_____Associate Member                        $100   (no business ownership)

_____Affiliate Member                            $100   (primary membership with Rawlins Chamber)