1.
General Membership Chairman’s Club
Membership Level:
2015 CAMPAIGN MEMBERSHIP APPLICATION
Phone: 770.232.3000 | Fax: 770.232.8807
gwinnettchamber.org | @GwinnettChamber
VOLUNTEER: _________________________________________________________
(Specify Other Social)
Additional Contacts: Please attach and specify. *Cell phone numbers are for internal use only and will not be shared for public use.
Organization Name: ____________________________________________________________________ Years In Business: _________
Public Telephone: ______________________ Fax: ______________________ FT Employees: ___________ PT Employees: __________
Physical Address: _________________________________________ City: ___________________ State: __________ Zip: ____________
Billing Address: __________________________________________ City: ___________________ State: __________ Zip: ____________
Industry/ Type of Business: ________________________________ Reason for Joining: ________________________________________
Twitter: _________________________________ Facebook: ___________________________ __________: _______________________
Primary Contact: _______________________________________________________ Title: ___________________________________
Direct Phone Number: _________________________ *Cell Phone: _________________________ Fax: __________________________
Contact Email Address: ________________________________________________ Office at Listed Address? Yes | No
Secondary Contact: _____________________________________________________ Title: ___________________________________
Direct Phone Number: _________________________ *Cell Phone: _________________________ Fax: __________________________
Contact Email Address: ________________________________________________ Office at Listed Address? Yes | No
Human Resources Contact: _______________________________________________ Title: ___________________________________
Direct Phone Number: _________________________ *Cell Phone: _________________________ Fax: __________________________
Contact Email Address: ________________________________________________ Office at Listed Address? Yes | No
Billing Contact: _________________________________________________________ Title: ___________________________________
Direct Phone Number: _________________________ *Cell Phone: _________________________ Fax: __________________________
Contact Email Address: ________________________________________________ Office at Listed Address? Yes | No
Marketing/ Sponsorship Contact: __________________________________________ Title: ___________________________________
Direct Phone Number: _________________________ *Cell Phone: _________________________ Fax: __________________________
Contact Email Address: ________________________________________________ Office at Listed Address? Yes | No
Gwinnett Chamber of Commerce | 6500 Sugarloaf Parkway | Duluth, Georgia 30097
President/CEO: Dr. Daniel J. Kaufman | Chairman of the Board: Mr. Randy Dellinger
Office Use Only:
WebLink: A/D: R/D: S/C:
____________________ ____________________ ____________________ ____________________
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Ann LaFavor
Luna West Foundation - Women Rebuilding Wealth, Inc
0 1
5415 Sugarloaf Pkwy Ste 1102 Lawrenceville GA 30043
PO Box 798 Lawrenceville GA 30046
not for profit
Melaine Cassells-Paramore founder
Melaine Cassells-Paramore founder

2.
Networking Events Program Sponsorship Hosting an Event
Chairman’s Club Speaking Prospect Catering an Event
Marketing Networking Legal Structure & Assistance
Social Media Minority Assistance Contracting & Procurement
Leadership Access to Capital Other (Please Specify Below)
Business Development Business Planning ____________________________________
NOTE: Membership dues will be billed one month prior to your anniversary date and payable upon receipt of invoice.
Annual Dues:
Circle Membership Type: Gen. Membership | Chairman’s Club
$35 Administrative Fee: (One-time Only)
Enhanced Web Listing:
Business After Hours Showcase Booth: (Save 20% by reserving a booth now! Reg: $125)
Month to Reserve: ______________________ Contact: _______________________
Program Sponsorship:
Program to Sponsor: ____________________ Contact: ________________________
TOTAL:
$____________________
$____________________
$____________________
$____________________
$____________________
$____________________
PLEASE CHECK ALL THAT APPLY:
Applicant Signature: ____________________________________ Print Name: ____________________________ Date: ____________
Chamber Signature: _________________________________________________________ Date: _______________________________
Gwinnett Chamber of Commerce | 6500 Sugarloaf Parkway | Duluth, Georgia 30097
President/CEO: Dr. Daniel J. Kaufman | Chairman of the Board: Mr. Randy Dellinger
Thank you for your interest in joining the Gwinnett Chamber. We look forward to serving you and your business. If you should need
anything during the course of your membership, please contact Vince DeSilva, Senior Vice President, Membership Services.
Email: vince@gwinnettchamber.org Phone: (770) 232-3000
Welcome to the Gwinnett Chamber of Commerce. To help maximize your membership investment and provide programs and
benefits that fit your business needs, please complete the survey below:
Membership Interest Survey
WHICH BUSINESS TOPICS MOST INTEREST YOUR COMPANY?
WHO IS THE BEST CONTACT PERSON TO DISCUSS THESE OPPORTUNITIES WITH FURTHER?
Name: __________________________________________________ Phone: ________________________________________________
Title: ___________________________________________________ Email: ________________________________________________
Additional Notes: _______________________________________________________________________________________________
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x
x
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Ann LaFavor 770 789 3255
mentor
300.00 (associate)
35.00
335.00