Membership Application Form

Fill out to register for membership with the Mount Isa Chamber of Commerce. Please complete the following form and forward to the Chamber office.

Fields labeled in RED must be completed.

	Membership Application Form
Membership Details:
Business Name:
Main Business Type:
ABN:
Business Phone:
Business Fax:
Web Address:
Postal Address:
Street Address:
Primary Representative Name:
Primary Representative Phone:
Primary Contact Email:

Secondary Representative:

Please include below additional staff members you would like included on the Chamber database.

Staff Member

Email Address

Telephone

The Mount Isa Chamber of Commerce values your right to privacy. In accordance with the Privacy Act of 1988 (Commonwealth)

The Mount Isa Chamber of Commerce may distribute the company name and phone number on the www.michamber.com.au website.
The Mount Isa Chamber of Commerce may distribute the company information on the Mount Isa Biz website ( www.mountisabiz )
The Mount Isa Chamber of Commerce may distribute the company information for statistical analysis of local businesses.

Membership Fees (incl GST):

Please check the box beside the business size that reflects the total number of employees in your business/organisation. An invoice upon approval will be sent to the postal address supplied for payment.

Check	Business Size	Membership Fee
	1 - 3 employees	$135.00
	4 - 9 employees	$185.00
	10 - 20 employees	$220.00
	21 + employees	$330.00

Sponsorship:

If you are interested in sponsorship please check the appropriate box.

Check	Event
	Bi-monthly Networking function
	Workshop, Conferences etc
	Mining Expo
	Green Week
	Business Awards
	Rodeo Best Dressed Premises Awards
	Service Excellence Awards

Membership Benefits are only applicable to the registered business name.

Membership applications must be proposed and seconded by an existing member and are subject to approval by the Management Committee.

	Name	Business	Telephone
Proposer:
Seconder:

Membership Application Form