New Member Information ILBCC - Membership Information Form ILBCC - Membership Information Form Member Information Name * Birthdate * Cell Number Phone Number * Current Address * City * State Zip Code * Website Email * Business Information Business Name * Business Address * How long? Phone Email Fax City State Zip Code Title Annual Projected Revenue Nature of Business * Business Size Small Mid Large DUNS Number NAICS Code Certifications Professional Affiliations & Organizations Organization Name How long? Organization Name How long? Organization Name How long? Professional References Name Address Phone Name Address Phone Name Address Phone Emergency Contact Name Address Phone City State Zip Code Relationship Signature * I confirmed all information provided on the application is true and by signing I agree to the terms and conditions of the Illinois State Black Chamber of Commerce (ILBCC). The funds remitted and information contained on this application is expressly used for an annual nonrefundable membership to ILBCC and its contents will not be sold or shared with non-members, sponsors or partners of ILBCC. Name * Date * Signature * * By submitting this form you agree to the terms of the Privacy Policy. Payment If you are human, leave this field blank. Submit Δ
