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Today's Date
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Business Name | |
Business Email | |
Physical Address | |
Physical Address City | |
Physical Address State | |
Physical Address Zip | |
Billing Address (if different) | |
Billing Address City (if different) | |
Billing Address State (if different) | |
Billing Address Zip (if different) | |
Mailing Address (if different) | |
Mailing Address City (if different) | |
Mailing Address State (if different) | |
Mailing Address Zip (if different) | |
Telephone | |
Alternate Telephone | |
Number of Employees | |
Fax Number | |
Website | |
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Annual Investment
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Your annual investment is determined by your gross revenues of the previous year. Please see the table below then select the appropriate option in the dropdown menu.
Gross Revenues
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Dues/Investment
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$10,000,000 and more
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$3,000
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$5,000,000 to $10,000,000
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$1,680
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$1,000,000 to $5,000,000
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$840
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| $500,000 to $1,000,000 |
$420
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Under $500,000
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$210
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Clubs and Organizations
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$165
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Church Memberships
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$130
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Individual Memberships
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$105
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Retired Individuals
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$50
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Primary Representative |
Primary Representative | |
Primary Representative's Title | |
Primary Representative's Email | |
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Billing Representative |
Billing Representative | |
Billing Representative's Title | |
Billing Representative's Email | |
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Additional Representatives | |
Business Description | |
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