Print this application and mail to:

229 South Broad Street
Lansdale, PA 19446

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Name of Business or Organization

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Street Address and Box Number

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City, Zip Code

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Phone Number

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Fax Number

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Email Address

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Website Address

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Type of Business

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Contact Person for Chamber

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Number of Employees

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Specify if you wish to offer discount or special service to other members

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List Committee Interest (If Applicable)

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Annual Dues Investment (See Chart) ( Include one-time $25 Application Fee)

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Primary Reason for Joining

Yes, I'm interested in advertising opportunities.
Yes, I've attached my business card.

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Signature of Representative

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Date