Membership Application

Membership Application
Membership in the Gaston Regional Chamber is an investment that will effectively support, promote, and enhance
through leadership and pride the interests of our member companies and their quality products and services with
emphasis on excellence in Gaston County.
Please fax this form to 704.854.8723 or mail this form to the Gaston Regional Chamber at 601 W. Franklin Blvd., Gastonia, NC, 28052.
MEMBER INFORMATION
Company Information ____________________________________________________________________________________________________________________
Firm Name ______________________________________________________________________________________________________________________________
Physical Address __________________________________________________________ City/State/ZIP _________________________________________________
Mailing Address __________________________________________________________ City/State/ZIP _________________________________________________
Phone 1 ______________________________ Phone 2 _ ___________________________________ FAX __________________________________________________
Email _ ______________________________________________________________ Web site www.____________________________________________________
Additional email _ _________________________________________________________________________________________________________________________
What is your preferred method of communication: Email US Mail
Business Classification (according to AT&T Yellow Pages) _______________________________________________________________________________________
Describe your product or service ___________________________________________________________________________________________________________
Main Contact ___________________________________________________________________ Title ____________________________________________________
Additional Contact _______________________________________________________________ Title ____________________________________________________
Number of employees: Full-time Equivalent (FTE) – two part-time equals one full-time _____________________________________________________________
What are the primary needs of your company? _______________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
INVESTMENT INFORMATION
Amount of annual Chamber investment (calculated by number of employees – refer to Investment Schedule below)
Method of payment
Credit Card
Card Holder Name _____________________________________________________________________________________________________________________
Card Number __________________________________________________________________________________________ Expiration ________ / __________
Check Make payable to Gaston Regional Chamber
Signature __________________________________________________________________________________________ Date _______________________________
Sponsor _________________________________________________________________________________________________________________________________
Annual Investment Schedule Banks/Savings & Loans: Investment is computed on a sliding scale based on $30 million in deposits.
1-5.................................. $280
6-15................................ $380 Dues paid to the Gaston Regional Chamber should be tax deductible as an ordnary business expense, not
16-50.............................. $550 a charitable contribution. A processing fee of $5.00 per billing cycle will be added to all accounts paid
51-100............................ $775 via credit card other than annually (either quarterly or semi-quaterly).
101-150.......................... $1008
151-300.......................... $1200 I authorize the Gaston Regional Chamber to bebit my checking account via ACH process, which is an
301-500.......................... $1620 automatic draft process, for $ on the the 30th of each month. For more information, contact Amanda
Above 501....................... $2000 Fieler at CommunityOne Bank at 704.865.4202.
Churches.................. $185
Non-profit................. $185
Individual Retired........ $185 Signature ______________________________________________________ Date ____________________

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