Amityville Chamber of Commerce
PO Box 885
Amityville, New York  11701

Application for Membership
July 1st - June 30th

New          ____                                                Date  _________________                                   
Renewal    ____                                             Dues enclosed __________

Proposed Member, Company or Organization:

______________________________________________________________

Primary Contact:____________________________  Tele:______________

Website: ___________________________________  Fax: ______________ 

Street Address: ________________________________________________

City: ________________________________, NY   Zip Code: ___________

Alternate Contact:  _________________________  Tele:_______________
                                            (If Applicable)       

Referred by: ___________________________________________________

If you are interested serving on a committee, or have some other interest
please let us know: ______________________________________________

I hereby apply for membership in the Amityville Chamber of Commerce, 
agree to pay dues annually in advance, and abide by the rules and 
regulations of the organization as set forth in its By-laws.

Signature:  _____________________________  Title: _________________