First Name *

Last Name *

Email Address *

Current Employer/Organization *

Business Address *

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State *

Zip *

Work Phone *

Cell Phone *

Please Choose One *

Is your business a current GIAEDC & Chamber Member?

Enter required value Member ($75) Non-Member ($130) Other

Who will be responsible for covering the membership fee? *

Enter required value I will be paying for the membership. My employer will be paying for the membership.

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Headshot Submission *

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Method of Payment *

Please make checks payable to GIAEDC & Chamber of Commerce.

If you prefer to pay online, kindly email elaudenklos@grandisland.org for payment instructions.

Enter required value Check Online