Application

New Paltz Passport
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Organization Information (to be displayed online)

Organization Name

Address 1

Address 2

City

State

Zip

Phone

Fax

Website

Main Contact

First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

Additional Contacts

Contact 1

First Name

Last Name

Title

Email Address

Contact 2

First Name

Last Name

Title

Email Address

Contact 3

First Name

Last Name

Title

Email Address

Contact 4

First Name

Last Name

Title

Email Address

Contact 5

First Name

Last Name

Title

Email Address

Contact 6

First Name

Last Name

Title

Email Address

Contact 7

First Name

Last Name

Title

Email Address

Contact 8

First Name

Last Name

Title

Email Address

Contact 9

First Name

Last Name

Title

Email Address

Contact 10

First Name

Last Name

Title

Email Address

Billing Address (if different)

Address 1

Address 2

City

State

Zip

Mailing Address (if different)

Address 1

Address 2

City

State

Zip

Additional Information

Referred By

How did you hear about us?

What is your reason for joining?

Please have someone contact me regarding

Business Resources
Community Involvement
Cost Savings Programs (Insurance, Office Supplies, Worker's Compensation)
Economic Development
Government Relations
Networking
Training Opportunities
Other

Membership Investment

Membership Type

Primary Directory Category

Additional Directory Categories

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Secondary categories may be subject to additional fees

Number of Full Time Employees

Number of Part Time Employees

Extra Website Words ($65)

Additional Branch ($105)

Enhanced Membership ($160)

Annual Membership Investment

Additional Items

Additional Categories Cost

Total

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Annual Dues (charged to card)

Revenue Item

Full-Time Employees

Part-Time Employees

Additional Item 1 Cost

Additional Item 2 Cost

Additional Item 3 Cost

Additional Categories Cost

Additional Categories

Number Of Additional Categories

One-Time Application Fee

Tax

Number of Rooms

Number of Seats

Number of Associates

Number of Locations

Millions in Assets

Hotel/Motel Rooms

Restaurant Seats

Additional Associates

Additional Associates Cost

Additional Locations

Additional Locations Cost

Assets

Assets Cost

Additional Item 4 Cost

Additional Item 5 Cost

Additional Item 6 Cost

Additional Item 7 Cost

Additional Item 8 Cost

Additional Item 9 Cost

Additional Item 10 Cost

Tax (charged to card)

Fee (charged to card)

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MembershipType

Additional Item 4

Additional Item 5

Additional Item 6

Additional Item 7

Additional Item 8

Additional Item 9

Additional Item 10

Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Credit Card Information

Credit Card Type MastercardVisaDiscoverAmex

Credit Card Number

Name on Card
Security Code
Valid Through
Address
City
State
Zip
Phone
Credit Card Email Address

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