Member Application

Kosciusko Chamber of Commerce

We are excited that you will be partnering with your Kosciusko Chamber of Commerce. We look forward to working together with you to promote your organization and continuing to build a strong community. Upon the completion of this application, your organization will be charged a one time application fee of $25 in addition to your annual membership dues.

Business Information

Company Name: *

Leave Blank:

Phone: *

Website: *

Email: *

Business Description (200 char max): *

Employees: *

Full-time Part-time

Comments / Questions:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Primary Contact Information

First Name: *

Last Name: *

Phone: *

Email: *

Contact Preference:

Email Phone

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Phone: *

Email: *

Contact Preference:

Email Phone

Membership Options

Additional Fees:

Membership Application Fee : $25.00
Membership Application Fee

Payment Option:

Bill me

Print Application

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Member Application

Kosciusko Chamber of Commerce

Contact Info

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