Member Application

Welcome and Thank You for your interest in the Ascension Chamber of Commerce.

Business Information

Company Name: *

Leave Blank:

Phone: *

Website:

Email: *

Business Description (200 char max): *

Directory Category: *

Employees: *

Full-time Part-time

Business Keywords (enter a space between words):

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: *

Social Networking:

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Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Print Application

Ascension Chamber of Commerce

1006 W. Highway 30

Gonzales, LA 70737

Phone: (225) 647-7487

Fax: (225) 647-5124

info@ascensionchamber.com

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