Membership Application

Your Name _____________________________________________ Your Title _______________________________________________ Company or Agency name ______________________________________________ Company Type ( ) Sole Proprietor / Business Owner ( ) For-Profit Corporation ( ) Non-Profit Corporation ( ) None (ie - employee or community member) Street Address ____________________________________________ City _________________________________ State _______ Zip __________ Day Phone ________________________ Cell/Night # ________________________ FAX number _______________________ Email Address _____________________________________________ Website Address (if any) _____________________________________________ Annual Membership Dues - One dues and one vote per company Business ( ) 1-10 Employees ($75) ( ) 11-or more Employees ($100) Non-Profit ( ) 1-10 Employees ($50) ( ) 11-or more Employees ($75) ( ) Community member or Non-administrative employee - $50 Please print and mail this completed form with your check made payable to Greater El Sereno Chamber of Commerce 2445 Mariondale Ave. Los Angeles, CA 90032