Member Application

To join, please fill out the application below.

For more information, please contact Jim O'Neil via email, Jim@cpbchamber.com, or call 561-578-4816.

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:

LinkedIn Facebook Twitter YouTube

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook Twitter YouTube

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

Password: *

Social Networking:

LinkedIn Facebook Twitter YouTube

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Starter Membership: $300.00
Supporter Membership: $580.00
Non Profit Membership: $225.00

Additional Fees:

One Time Admin Fee : $35.00
One time admin fee.

Payment Option:

Charge my credit or debit card

Print Application