Cowlitz Economic Development Council - Facilitating Growth Through Leadership & Action

Please fill out this form and send with payment by check,
money order or credit card information to:

Cowlitz Economic Development Council
1452 Hudson Street
P.O. Box 1278
Longview, WA 98632

You may also fax your request to:
Fax: (360) 423-1923

Membership Application

Company:

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Contact Person:

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Title:

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E-mail:

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Mailing Address:

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City:

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State:

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Country:

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Zip Code:

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Telephone:

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Fax:

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Web Site:

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Business description:

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Payment Method:

__ Visa
__ Mastercard
__ Check

Credit Card Information:

Name on Card:________________________________________

Card Billing Address:___________________________________

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Card Number:_________________________________________

Expiration Date:_______________________________________

Total Purchase:$______________________________________

Membership type:

	Total Number of Employees:	Minimum Investment:
___	Retired Individuals	$155.00
___	Nonprofit	$325.00
___	Financial Institutions	$900.00
___	1 To 5 Employees	$325.00
___	6 To 25 Employees	$385.00
___	26 To 50 Employees	$765.00
___	51 To 100 Employees	$1520.00
___	101 To 200 Employees	$2400.00
___	More Than 200 Employees	$3500.00

Your Signature:

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Toady's Date:

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