Application for Membership

Please Print ALL Information

Title:   []Mr.   [] Mrs.  [] Ms.   [] Other___________

  ________________________________________
First Name

  ________________________________________
Last Name

  ____________________________________________
Position/Title

  ____________________________________________
Organization/Company Name

  ____________________________________________
Mailing Address

  ____________________________________________
                          Street Address                        

  ____________________________________________
   City                              State                       Zip Code

  (____)_______________(_____)__________________
Home Phone                         Work Phone              EXT

  (_____)____________     _________
Fax Number                 Pager 

  _______________________     
Cell  Phone

  ____________________________________________
E-Mail Address

  ____________________________________________
Web Page Address

  ____________________________________________
Spouse's Name

  ____________________________________________
Signature of Applicant

  ____________________________________________
Referred By

  ANNUAL DUES:  $50.00 for Business Voting Members                  

                                             $25.00 for Non-Voting Associate Members

  AMOUNT ENCLOSED WITH APPLICATION  $________________

Each business may have a maximum of two (2) Voting members.  The number of Associate Members is not limited.  

Mail this application with your check payable to the King William Business Association, Inc. at:

King William Business Association, Inc.
P.O. Box 403
Manquin, VA 23106-0403