business.hwcoc.org
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URL:
https://business.hwcoc.org/member/NewMemberApp/
Submission: On March 07 via api from US — Scanned from DE
Submission: On March 07 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: NewMemberApp — POST https://business.hwcoc.org/member/newmemberapp
<form action="https://business.hwcoc.org/member/newmemberapp" method="post" name="NewMemberApp"> <input type="hidden" name="NewMemberInfo.AtomicGUID" value="24550265-ccb1-4fa2-be13-fcd8afb74437">
<div id="mn-memberapp-business" class="mn-section">
<div class="mn-section-head">
<div class="mn-section-head-text">Business Information</div>
</div>
<div class="mn-section-content">
<div id="mn-memberapp-companyname" class="mn-form-row">
<label>
<span class="mn-form-name"> Company Name: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="80" name="NewMemberInfo.MemCompanyName" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-blank" class="mn-form-row" style="display:none">
<label>
<span class="mn-form-name"> Leave Blank: </span>
<span class="mn-form-field"><input autocomplete="off" class="mn-form-text" maxlength="80" name="NewMemberInfo.AlternateEmail" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-phone" class="mn-form-row">
<label>
<span class="mn-form-name"> Phone: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.MemPhone" size="20" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-website" class="mn-form-row">
<label>
<span class="mn-form-name"> Website: </span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="100" name="NewMemberInfo.MemWebSite" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-email" class="mn-form-row">
<label>
<span class="mn-form-name"> Email: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="60" name="NewMemberInfo.MemEMail" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-fulldesc" class="mn-form-row">
<label>
<span class="mn-form-name"> Business Description (500 char max): </span>
<span class="mn-form-field"><textarea class="mn-form-text" cols="35" maxlength="500" name="NewMemberInfo.MemFullDesc" rows="3"></textarea></span>
</label>
</div>
<div id="mn-memberapp-buscatpri" class="mn-form-row">
<label>
<span class="mn-form-name"> Directory Category: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><select class="mn-form-dropdown" id="NewMemberInfo_MemBusCatPri" name="NewMemberInfo.MemBusCatPri">
<option value="">--- Select Primary Category ---</option>
<option value="60">ACCOUNTANTS/CERTIFIED PUBLIC</option>
<option value="1">ADVERTISING/GRAPHICS</option>
<option value="106">ADVISORY BOARD</option>
<option value="62">AIR CONDITIONING & HEATING </option>
<option value="13">APARTMENTS </option>
<option value="12">ARTS, AMUSEMENT & ENTERTAINMENT</option>
<option value="39">ASSISTED LIVING & RETIREMENT COMMUNITY</option>
<option value="2">ATTORNEYS</option>
<option value="14">AUTOMOTIVE</option>
<option value="29">BAKERY & CAFES</option>
<option value="15">BANKS</option>
<option value="46">BEAUTY SALONS & SPAS</option>
<option value="104">BUSINESS BUILDER MEMBER</option>
<option value="16">BUSINESS CONSULTANTS</option>
<option value="31">BUSINESS SERVICES</option>
<option value="122">CARPET & FLOORING</option>
<option value="71">CATERING, EVENTS & VENUES</option>
<option value="98">CHAIRMAN'S CIRCLE MEMBER</option>
<option value="58">CHURCHES</option>
<option value="36">CLUBS & ORGANIZATIONS</option>
<option value="127">CONFERENCE CENTER</option>
<option value="85">COURIER SERVICE</option>
<option value="133">CREDIT RESTORATION</option>
<option value="116">CREDIT UNIONS</option>
<option value="79">DENTAL SERVICES</option>
<option value="129">DIAMOND PARTNER</option>
<option value="37">EDUCATION</option>
<option value="66">EMBROIDERY & SCREENPRINTING</option>
<option value="6">ENERGY PROVIDER</option>
<option value="91">ENGINEERING, CONSTRUCTION & TECHNICAL SERVICES</option>
<option value="132">FINANCIAL LITERACY</option>
<option value="82">FITNESS CENTER</option>
<option value="73">FLORAL & SPECIAL ARRANGEMENTS</option>
<option value="48">FUNERAL SERVICES</option>
<option value="17">GENERAL & ELECTRICAL CONTRACTORS</option>
<option value="47">GOLF CLUB</option>
<option value="45">GOVERNMENT & ELECTED OFFICIALS</option>
<option value="68">GROCERY STORES</option>
<option value="134">HEALTH & WELLNESS</option>
<option value="125">HOSPITALITY</option>
<option value="80">HOSPITALS & URGENT CARE FACILITIES</option>
<option value="19">HOTEL/MOTEL</option>
<option value="117">HR & PAYROLL</option>
<option value="44">IMPORT/EXPORT</option>
<option value="20">INSURANCE</option>
<option value="96">INTERIOR DECORATING</option>
<option value="50">INVESTIGATIONS</option>
<option value="21">INVESTMENT & FINANCIAL SERVICES</option>
<option value="38">IT/TECHNOLOGY</option>
<option value="120">JANITORIAL SERVICES/SUPPLIES</option>
<option value="115">JEWELRY</option>
<option value="72">LANDSCAPING</option>
<option value="93">LOCKSMITH</option>
<option value="22">MANUFACTURERS & PROCESSORS</option>
<option value="70">MARKETING/PUBLIC RELATIONS</option>
<option value="83">MASSAGE THERAPY</option>
<option value="35">MEDICAL SERVICES</option>
<option value="128">MEMORY & DEMENTIA CARE</option>
<option value="67">MORTGAGE COMPANIES</option>
<option value="89">MOVING</option>
<option value="121">NETWORKING ORGANIZATION</option>
<option value="42">NON-PROFIT</option>
<option value="126">OFFICE SPACES</option>
<option value="49">OFFICE SUPPLIES/EQUIPMENT</option>
<option value="9">OIL & GAS</option>
<option value="108">OPTOMETRY</option>
<option value="52">PACKING & SHIPPING</option>
<option value="53">PERSONNEL & STAFFING</option>
<option value="84">PHARMACY</option>
<option value="57">PHOTOGRAPHY/VIDEOGRAPHY</option>
<option value="101">PLATINUM PARTNER MEMBER</option>
<option value="111">PLUMBING</option>
<option value="74">PRINTING & GRAPHICS</option>
<option value="113">PROMOTIONAL PRODUCTS</option>
<option value="25">PUBLISHERS</option>
<option value="27">RADIO & TELEVISION</option>
<option value="28">REAL ESTATE</option>
<option value="124">Real Estate</option>
<option value="123">REMEDIATION & SANITIZING </option>
<option value="10">RESTAURANT</option>
<option value="30">RETAILERS</option>
<option value="109">SECURITY</option>
<option value="90">SENIOR CARE</option>
<option value="102">SIGNATURE SPONSOR</option>
<option value="99">SOCIAL MEDIA</option>
<option value="118">SPORTS</option>
<option value="87">STORAGE FACILITIES</option>
<option value="107">STUDIO/SHOWROOM</option>
<option value="81">TELECOMMUNICATIONS</option>
<option value="97">TITLE COMPANY</option>
<option value="32">TRANSPORTATION</option>
<option value="56">TRAVEL AGENCY</option>
<option value="78">VETERINARY & ANIMAL CLINICS</option>
<option value="119">WASTE MANAGEMENT/DISPOSAL</option>
<option value="75">WEB MARKETING</option>
<option value="33">WELLNESS & NUTRITION</option>
<option value="34">WHOLESALE & DISTRIBUTORS</option>
</select></span>
</label>
</div>
<div id="mn-memberapp-empcount" class="mn-form-row">
<div class="mn-form-name"> Employees: <span class="mn-form-req" title="Required field">*</span>
</div>
<div class="mn-form-combo mn-form-textcombo">
<label id="mn-memberapp-empfulltime">
<span class="mn-form-name">Full-time</span>
<span class="mn-form-field"><input class="mn-form-text" name="NewMemberInfo.MemEmpFullTime" size="5" type="text" value=""></span>
</label>
<label id="mn-memberapp-empparttime">
<span class="mn-form-name">Part-time</span>
<span class="mn-form-field"><input class="mn-form-text" name="NewMemberInfo.MemEmpPartTime" size="5" type="text" value=""></span>
</label>
<div class="mn-clear"></div>
</div>
</div>
<div id="mn-memberapp-keywords" class="mn-form-row">
<label>
<span class="mn-form-name"> Business Keywords (enter a space between words): </span>
<span class="mn-form-field"><textarea class="mn-form-text" cols="35" maxlength="240" name="NewMemberInfo.MemKeyword1" rows="3"></textarea></span>
</label>
</div>
<div id="mn-memberapp-commentquest" class="mn-form-row">
<label>
<span class="mn-form-name"> Comments / Questions: </span>
<span class="mn-form-field"><textarea class="mn-form-text" cols="35" name="NewMemberInfo.MemberCommentQuest" rows="3"></textarea></span>
</label>
</div>
<div id="mn-memberapp-cf40" class="mn-form-row">
<label>
<span class="mn-form-name"> Referred by: </span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="12" name="cf_40" size="12" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-cf95" class="mn-form-row">
<label>
<span class="mn-form-name"> Did a member of our staff assist you with your Chamber membership?: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><select class="mn-form-dropdown" id="cf_95" name="cf_95">
<option value=""></option>
<option value="47">Yes</option>
<option value="48">No</option>
</select></span>
</label>
</div>
<div id="mn-memberapp-cf94" class="mn-form-row">
<label>
<span class="mn-form-name"> If so, Please indicate which member of our staff assisted you: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><select class="mn-form-dropdown" id="cf_94" name="cf_94">
<option value=""></option>
<option value="41">Kari Werner</option>
<option value="46">Shawnda Peters</option>
<option value="44">Devyn Waggoner</option>
<option value="50">Monica Viveros</option>
<option value="51">Ashley Smith</option>
<option value="53">Jeffrey Reich-Hale</option>
<option value="49">No staff member assisted me</option>
</select></span>
</label>
</div>
<div id="mn-memberapp-cf27" class="mn-form-row">
<label>
<span class="mn-form-name"> How did you hear about the chamber?: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="50" name="cf_27" size="50" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-cf82" class="mn-form-row">
<label>
<span class="mn-form-name"> Please select your top reason for joining: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><select class="mn-form-dropdown" id="cf_82" name="cf_82">
<option value=""></option>
<option value="12">Sales/Profit</option>
<option value="13">Visibility/Marketing</option>
<option value="14">Networking</option>
<option value="15">Education/Seminars</option>
<option value="16">Ribbon Cutting</option>
<option value="17">Certificate of Origin</option>
<option value="18">Other</option>
</select></span>
</label>
</div>
<div id="mn-memberapp-cf87" class="mn-form-row">
<label>
<span class="mn-form-name"> I give permission for the HWCOC to email/fax/mail info to my business: </span>
<span class="mn-form-field"><select class="mn-form-dropdown" id="cf_87" name="cf_87">
<option value=""></option>
<option value="19">Yes</option>
<option value="20">No</option>
</select></span>
</label>
</div>
<div id="mn-memberapp-cf88" class="mn-form-row">
<label>
<span class="mn-form-name"> I give permission to list my business on online directory: </span>
<span class="mn-form-field"><select class="mn-form-dropdown" id="cf_88" name="cf_88">
<option value=""></option>
<option value="21">Yes</option>
<option value="22">No</option>
</select></span>
</label>
</div>
</div>
<div id="mn-memberapp-physadrs" class="mn-section">
<div class="mn-form-title">Physical Address</div>
<div id="mn-memberapp-physadrs1" class="mn-form-row mn-memberappadrs1">
<label>
<span class="mn-form-name"> Line 1: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="40" name="NewMemberInfo.MemPhysAdrs1" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-physadrs2" class="mn-form-row mn-memberappadrs2">
<label>
<span class="mn-form-name">Line 2:</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="40" name="NewMemberInfo.MemPhysAdrs2" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-physcity" class="mn-form-row mn-memberappcity">
<label>
<span class="mn-form-name"> City: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.MemPhysCity" size="20" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-physstate" class="mn-form-row mn-memberappstate">
<label>
<span class="mn-form-name"> State: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="20" name="NewMemberInfo.MemPhysState" size="2" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-physzip" class="mn-form-row mn-memberappzip">
<label>
<span class="mn-form-name"> Postal Code: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="15" name="NewMemberInfo.MemPhysZip" size="11" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-physcountry" class="mn-form-row mn-memberappcountry">
<label>
<span class="mn-form-name"> Country: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field">
<select class="mn-form-dropdown" id="NewMemberInfo_MemPhysCountry" name="NewMemberInfo.MemPhysCountry">
<option value="">--- Select Country ---</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BM">Bermuda</option>
<option value="BM">Bermuda</option>
<option value="VE">Bolivarian Republic of Venezuela</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BR">Brazil</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="029">Caribbean</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CD">Congo [DRC]</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FO">Faroe Islands</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GT">Guatemala</option>
<option value="HT">Haiti</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HK">Hong Kong SAR</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="CI">Ivory Coast</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KR">Korea</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao PDR</option>
<option value="419">Latin America</option>
<option value="LV">Latvia</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao SAR</option>
<option value="MK">Macedonia (Former Yugoslav Republic of Macedonia)</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MX">Mexico</option>
<option value="MD">Moldova</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MA">Morocco</option>
<option value="MM">Myanmar</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NG">Nigeria</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PA">Panama</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="MC">Principality of Monaco</option>
<option value="PR">Puerto Rico</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="CS">Serbia and Montenegro (Former)</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TH">Thailand</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="AE">U.A.E.</option>
<option value="UA">Ukraine</option>
<option value="GB">United Kingdom</option>
<option selected="selected" value="US">United States</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VN">Vietnam</option>
<option value="YE">Yemen</option>
</select> </span>
</label>
</div>
</div>
<div id="mn-memberapp-mail" class="mn-section">
<h3>Mailing Address</h3>
<div id="mn-memberapp-mailadrssame" class="mn-form-row">
<label>
<span class="mn-form-field"><input class="mn-form-check" id="NewMemberInfo_MemMailAdrsIsPhysAdrs" name="NewMemberInfo.MemMailAdrsIsPhysAdrs" type="checkbox" value="true"><input name="NewMemberInfo.MemMailAdrsIsPhysAdrs" type="hidden"
value="false"></span>
<span class="mn-form-name">Same as physical address</span>
</label>
</div>
<div id="mn-memberapp-mailadrs1" class="mn-form-row mn-memberappadrs1 mn-memberapp-mailadrssame-toggle">
<label>
<span class="mn-form-name"> Line 1: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="40" name="NewMemberInfo.MemMailAdrs1" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-mailadrs2" class="mn-form-row mn-memberappadrs2 mn-memberapp-mailadrssame-toggle">
<label>
<span class="mn-form-name">Line 2:</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="40" name="NewMemberInfo.MemMailAdrs2" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-mailcity" class="mn-form-row mn-memberappcity mn-memberapp-mailadrssame-toggle">
<label>
<span class="mn-form-name"> City: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.MemMailCity" size="20" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-mailstate" class="mn-form-row mn-memberappstate mn-memberapp-mailadrssame-toggle">
<label>
<span class="mn-form-name"> State: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="20" name="NewMemberInfo.MemMailState" size="2" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-mailzip" class="mn-form-row mn-memberappzip mn-memberapp-mailadrssame-toggle">
<label>
<span class="mn-form-name"> Postal Code: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="15" name="NewMemberInfo.MemMailZip" size="11" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-mailcountry" class="mn-form-row mn-memberappcountry mn-memberapp-mailadrssame-toggle">
<label>
<span class="mn-form-name"> Country: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field">
<select class="mn-form-dropdown" id="NewMemberInfo_MemMailCountry" name="NewMemberInfo.MemMailCountry">
<option value="">--- Select Country ---</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BM">Bermuda</option>
<option value="BM">Bermuda</option>
<option value="VE">Bolivarian Republic of Venezuela</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BR">Brazil</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="029">Caribbean</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CD">Congo [DRC]</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FO">Faroe Islands</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GT">Guatemala</option>
<option value="HT">Haiti</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HK">Hong Kong SAR</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="CI">Ivory Coast</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KR">Korea</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao PDR</option>
<option value="419">Latin America</option>
<option value="LV">Latvia</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao SAR</option>
<option value="MK">Macedonia (Former Yugoslav Republic of Macedonia)</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MX">Mexico</option>
<option value="MD">Moldova</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MA">Morocco</option>
<option value="MM">Myanmar</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NG">Nigeria</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PA">Panama</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="MC">Principality of Monaco</option>
<option value="PR">Puerto Rico</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="CS">Serbia and Montenegro (Former)</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TH">Thailand</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="AE">U.A.E.</option>
<option value="UA">Ukraine</option>
<option value="GB">United Kingdom</option>
<option selected="selected" value="US">United States</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VN">Vietnam</option>
<option value="YE">Yemen</option>
</select> </span>
</label>
</div>
</div>
<div id="mn-memberapp-mbrsocialnetwork" class="mn-section mn-memberapp-mbrsocialnetwork">
<div class="mn-form-title"> Social Networking: </div>
<div class="mn-form-row mn-form-textcombo">
<label class="mn-memberapp-mbrsocialnetwork1">
<span class="mn-form-name">LinkedIn</span>
<span class="mn-form-field"><input class="mn-form-text" data-value="http://www.linkedin.com" maxlength="100" name="MbrSocialNetworkID_1" size="40" type="text" value="http://www.linkedin.com"></span>
</label>
<label class="mn-memberapp-mbrsocialnetwork2">
<span class="mn-form-name">Facebook</span>
<span class="mn-form-field"><input class="mn-form-text" data-value="http://facebook.com/pages/" maxlength="100" name="MbrSocialNetworkID_2" size="40" type="text" value="http://facebook.com/pages/"></span>
</label>
<label class="mn-memberapp-mbrsocialnetwork11">
<span class="mn-form-name">Twitter</span>
<span class="mn-form-field"><input class="mn-form-text" data-value="http://twitter.com/" maxlength="100" name="MbrSocialNetworkID_11" size="40" type="text" value="http://twitter.com/"></span>
</label>
<label class="mn-memberapp-mbrsocialnetwork12">
<span class="mn-form-name">You Tube</span>
<span class="mn-form-field"><input class="mn-form-text" data-value="www.youtube.com" maxlength="100" name="MbrSocialNetworkID_12" size="40" type="text" value="www.youtube.com"></span>
</label>
<label class="mn-memberapp-mbrsocialnetwork13">
<span class="mn-form-name">Yelp</span>
<span class="mn-form-field"><input class="mn-form-text" data-value="http://www.yelp.com/houston" maxlength="100" name="MbrSocialNetworkID_13" size="40" type="text" value="http://www.yelp.com/houston"></span>
</label>
<label class="mn-memberapp-mbrsocialnetwork15">
<span class="mn-form-name">Instagram</span>
<span class="mn-form-field"><input class="mn-form-text" data-value="https://www.instagram.com/" maxlength="100" name="MbrSocialNetworkID_15" size="40" type="text" value="https://www.instagram.com/"></span>
</label>
</div>
</div>
</div>
<div id="mn-memberapp-prirep" class="mn-section">
<div class="mn-section-head">
<div class="mn-section-head-text">Primary Contact Information</div>
</div>
<div class="mn-section-content">
<div id="mn-memberapp-prirepfirstname" class="mn-form-row mn-memberapp-repfirstname">
<label>
<span class="mn-form-name"> First Name: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="50" name="NewMemberInfo.PriRepFirstName" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prireplastname" class="mn-form-row mn-memberapp-replastname">
<label>
<span class="mn-form-name"> Last Name: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="50" name="NewMemberInfo.PriRepLastName" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prireptitle" class="mn-form-row mn-memberapp-reptitle">
<label>
<span class="mn-form-name"> Title: </span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="50" name="NewMemberInfo.PriRepTitle" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepphone" class="mn-form-row mn-memberapp-repphone">
<label>
<span class="mn-form-name"> Phone: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.PriRepPhone" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepcellphone" class="mn-form-row mn-memberapp-repcellphone">
<label>
<span class="mn-form-name"> Cell Phone: </span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.PriRepCellPhone" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepfax" class="mn-form-row mn-memberapp-repfax">
<label>
<span class="mn-form-name"> Fax: </span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.PriRepFax" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepemail" class="mn-form-row mn-memberapp-repemail">
<label>
<span class="mn-form-name"> Email: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="80" name="NewMemberInfo.PriRepEMail" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepcontactpref" class="mn-form-row mn-memberapp-repcontactpref">
<div class="mn-form-title">Contact Preference:</div>
<div class="mn-form-combo mn-form-radiocombo">
<label id="mn-memberapp-prirepcontactprefEmail" class="mn-memberapp-repcontactprefEmail">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.PriRepContactPref" type="radio" value="EMail"></span>
<span class="mn-form-name">Email</span>
</label>
<label id="mn-memberapp-prirepcontactprefPhone" class="mn-memberapp-repcontactprefPhone">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.PriRepContactPref" type="radio" value="Phone"></span>
<span class="mn-form-name">Phone</span>
</label>
</div>
</div>
<div id="mn-memberapp-prirepmail">
<h3>Address</h3>
<div id="mn-memberapp-prirepmailadrssame" class="mn-form-row mn-memberapp-repadrssame">
<label>
<span class="mn-form-field"><input class="mn-form-check" id="NewMemberInfo_PriRepMailAdrsIsCompanyAdrs" name="NewMemberInfo.PriRepMailAdrsIsCompanyAdrs" type="checkbox" value="true"><input name="NewMemberInfo.PriRepMailAdrsIsCompanyAdrs"
type="hidden" value="false"></span>
<span class="mn-form-name">Same as Member Address</span>
</label>
</div>
<div id="mn-memberapp-prirepmailadrs1" class="mn-form-row mn-memberappadrs1 mn-memberapp-prirepmailadrssame-toggle">
<label>
<span class="mn-form-name"> Line 1: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="100" name="NewMemberInfo.PriRepMailAdrs1" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepmailadrs2" class="mn-form-row mn-memberappadrs2 mn-memberapp-prirepmailadrssame-toggle">
<label>
<span class="mn-form-name">Line 2</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="100" name="NewMemberInfo.PriRepMailAdrs2" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepmailcity" class="mn-form-row mn-memberappcity mn-memberapp-prirepmailadrssame-toggle">
<label>
<span class="mn-form-name"> City: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.PriRepMailCity" size="20" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepmailstate" class="mn-form-row mn-memberappstate mn-memberapp-prirepmailadrssame-toggle">
<label>
<span class="mn-form-name"> State: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="20" name="NewMemberInfo.PriRepMailState" size="2" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepmailzip" class="mn-form-row mn-memberappzip mn-memberapp-prirepmailadrssame-toggle">
<label>
<span class="mn-form-name"> Postal Code: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="15" name="NewMemberInfo.PriRepMailZip" size="11" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-prirepmailcountry" class="mn-form-row mn-memberappcountry mn-memberapp-prirepmailadrssame-toggle">
<label>
<span class="mn-form-name"> Country: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field">
<select class="mn-form-dropdown" id="NewMemberInfo_PriRepMailCountry" name="NewMemberInfo.PriRepMailCountry">
<option value="">--- Select Country ---</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BM">Bermuda</option>
<option value="BM">Bermuda</option>
<option value="VE">Bolivarian Republic of Venezuela</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BR">Brazil</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="029">Caribbean</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CD">Congo [DRC]</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FO">Faroe Islands</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GT">Guatemala</option>
<option value="HT">Haiti</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HK">Hong Kong SAR</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="CI">Ivory Coast</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KR">Korea</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao PDR</option>
<option value="419">Latin America</option>
<option value="LV">Latvia</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao SAR</option>
<option value="MK">Macedonia (Former Yugoslav Republic of Macedonia)</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MX">Mexico</option>
<option value="MD">Moldova</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MA">Morocco</option>
<option value="MM">Myanmar</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NG">Nigeria</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PA">Panama</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="MC">Principality of Monaco</option>
<option value="PR">Puerto Rico</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="CS">Serbia and Montenegro (Former)</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TH">Thailand</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="AE">U.A.E.</option>
<option value="UA">Ukraine</option>
<option value="GB">United Kingdom</option>
<option selected="selected" value="US">United States</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VN">Vietnam</option>
<option value="YE">Yemen</option>
</select> </span>
</label>
</div>
</div>
</div>
</div>
<div id="mn-memberapp-billrep" class="mn-section">
<div class="mn-section-head">
<div class="mn-section-head-text">Billing Contact Information</div>
</div>
<div class="mn-section-content">
<div id="mn-memberapp-billrepsame" class="mn-form-row">
<label>
<span class="mn-form-field"><input class="mn-form-check" name="NewMemberInfo.PriRepIsBillRep" type="checkbox" value="true"><input name="NewMemberInfo.PriRepIsBillRep" type="hidden" value="false"></span>
<span class="mn-form-name">Same as Primary Contact</span>
</label>
</div>
<div id="mn-memberapp-billrepfirstname" class="mn-form-row mn-memberapp-repfirstname mn-memberapp-billrepsame-toggle">
<label>
<span class="mn-form-name"> First Name: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="50" name="NewMemberInfo.BillRepFirstName" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billreplastname" class="mn-form-row mn-memberapp-replastname mn-memberapp-billrepsame-toggle">
<label>
<span class="mn-form-name"> Last Name: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="50" name="NewMemberInfo.BillRepLastName" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billreptitle" class="mn-form-row mn-memberapp-reptitle mn-memberapp-billrepsame-toggle">
<label>
<span class="mn-form-name"> Title: </span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="50" name="NewMemberInfo.BillRepTitle" size="48" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepphone" class="mn-form-row mn-memberapp-repphone mn-memberapp-billrepsame-toggle">
<label>
<span class="mn-form-name"> Phone: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.BillRepPhone" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepcellphone" class="mn-form-row mn-memberapp-repcellphone mn-memberapp-billrepsame-toggle">
<label>
<span class="mn-form-name"> Cell Phone: </span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.BillRepCellPhone" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepfax" class="mn-form-row mn-memberapp-repfax mn-memberapp-billrepsame-toggle">
<label>
<span class="mn-form-name"> Fax: </span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="30" name="NewMemberInfo.BillRepFax" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepemail" class="mn-form-row mn-memberapp-repemail mn-memberapp-billrepsame-toggle">
<label>
<span class="mn-form-name"> Email: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="80" name="NewMemberInfo.BillRepEMail" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepcontactpref" class="mn-form-row mn-memberapp-repcontactpref mn-memberapp-billrepsame-toggle">
<div class="mn-form-title">Contact Preference:</div>
<div class="mn-form-combo mn-form-radiocombo">
<label id="mn-memberapp-billrepcontactprefEmail" class="mn-memberapp-repcontactprefEmail">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.BillRepContactPref" type="radio" value="EMail"></span>
<span class="mn-form-name">Email</span>
</label>
<label id="mn-memberapp-billrepcontactprefPhone" class="mn-memberapp-repcontactprefPhone">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.BillRepContactPref" type="radio" value="Phone"></span>
<span class="mn-form-name">Phone</span>
</label>
</div>
</div>
<div id="mn-memberapp-billrepmail" class="mn-memberapp-billrepsame-toggle">
<h3>Address</h3>
<div id="mn-memberapp-billrepmailadrssame" class="mn-form-row mn-memberapp-repadrssame">
<label>
<span class="mn-form-field"><input class="mn-form-check" id="NewMemberInfo_BillRepMailAdrsIsCompanyAdrs" name="NewMemberInfo.BillRepMailAdrsIsCompanyAdrs" type="checkbox" value="true"><input
name="NewMemberInfo.BillRepMailAdrsIsCompanyAdrs" type="hidden" value="false"></span>
<span class="mn-form-name">Same as Member Address</span>
</label>
</div>
<div id="mn-memberapp-billrepmailadrs1" class="mn-form-row mn-memberappadrs1 mn-memberapp-billrepmailadrssame-toggle">
<label>
<span class="mn-form-name"> Line 1: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="100" name="NewMemberInfo.BillRepMailAdrs1" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepmailadrs2" class="mn-form-row mn-memberappadrs2 mn-memberapp-billrepmailadrssame-toggle">
<label>
<span class="mn-form-name">Line 2</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="100" name="NewMemberInfo.BillRepMailAdrs2" size="45" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepmailcity" class="mn-form-row mn-memberappcity mn-memberapp-billrepmailadrssame-toggle">
<label>
<span class="mn-form-name"> City: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="50" name="NewMemberInfo.BillRepMailCity" size="20" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepmailstate" class="mn-form-row mn-memberappstate mn-memberapp-billrepmailadrssame-toggle">
<label>
<span class="mn-form-name"> State: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="20" name="NewMemberInfo.BillRepMailState" size="2" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepmailzip" class="mn-form-row mn-memberappzip mn-memberapp-billrepmailadrssame-toggle">
<label>
<span class="mn-form-name"> Postal Code: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field"><input class="mn-form-text" maxlength="10" name="NewMemberInfo.BillRepMailZip" size="11" type="text" value=""></span>
</label>
</div>
<div id="mn-memberapp-billrepmailcountry" class="mn-form-row mn-memberappcountry mn-memberapp-billrepmailadrssame-toggle">
<label>
<span class="mn-form-name"> Country: <span class="mn-form-req" title="Required field">*</span>
</span>
<span class="mn-form-field">
<select class="mn-form-dropdown" id="NewMemberInfo_BillRepMailCountry" name="NewMemberInfo.BillRepMailCountry">
<option value="">--- Select Country ---</option>
<option>Canada</option>
<option>United States</option>
</select> </span>
</label>
</div>
</div>
</div>
</div>
<div id="mn-memberapp-memopts" class="mn-section">
<div class="mn-section-head">
<div class="mn-section-head-text">Membership Options</div>
</div>
<div class="mn-section-content">
<div id="mn-memberapp-package" class="mn-form-row">
<div class="mn-form-title"> Membership Package: <span class="mn-form-req" title="Required field">*</span>
</div>
<div class="mn-form-combo mn-form-radiocombo">
<label id="mn-memberapp-package16">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MemberAppPkg" type="radio" value="16"></span>
<span class="mn-form-name">
<span class="mn-memberapp-pkgname">Basic Membership (Yearly)</span>: <span class="mn-memberapp-pkgfee"> $400.00 </span><br>
<span class="mn-memberapp-pkgdesc"></span>
</span>
</label>
<label id="mn-memberapp-package8">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MemberAppPkg" type="radio" value="8"></span>
<span class="mn-form-name">
<span class="mn-memberapp-pkgname">Business Builder</span>: <span class="mn-memberapp-pkgfee"> $755.00 </span><br>
<span class="mn-memberapp-pkgdesc">Ribbon Cutting and Certificate of Origin</span>
</span>
</label>
<label id="mn-memberapp-package10">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MemberAppPkg" type="radio" value="10"></span>
<span class="mn-form-name">
<span class="mn-memberapp-pkgname">Chairman's Circle (1-Yr)</span>: <span class="mn-memberapp-pkgfee"> $1,995.00 </span><br>
<span class="mn-memberapp-pkgdesc"></span>
</span>
</label>
<label id="mn-memberapp-package17">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MemberAppPkg" type="radio" value="17"></span>
<span class="mn-form-name">
<span class="mn-memberapp-pkgname">Chairman's Circle (2-Yr)</span>: <span class="mn-memberapp-pkgfee"> $3,595.00 </span><br>
<span class="mn-memberapp-pkgdesc"></span>
</span>
</label>
<label id="mn-memberapp-package12">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MemberAppPkg" type="radio" value="12"></span>
<span class="mn-form-name">
<span class="mn-memberapp-pkgname">Platinum Partner (1-Yr)</span>: <span class="mn-memberapp-pkgfee"> $3,995.00 </span><br>
<span class="mn-memberapp-pkgdesc"></span>
</span>
</label>
<label id="mn-memberapp-package18">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MemberAppPkg" type="radio" value="18"></span>
<span class="mn-form-name">
<span class="mn-memberapp-pkgname">Platinum Partner (2-Yr)</span>: <span class="mn-memberapp-pkgfee"> $7,195.00 </span><br>
<span class="mn-memberapp-pkgdesc"></span>
</span>
</label>
<label id="mn-memberapp-package14">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MemberAppPkg" type="radio" value="14"></span>
<span class="mn-form-name">
<span class="mn-memberapp-pkgname">Non-Profit Membership</span>: <span class="mn-memberapp-pkgfee"> $300.00 </span><br>
<span class="mn-memberapp-pkgdesc">Proof of 501(c)3 status is required. </span>
</span>
</label>
<label id="mn-memberapp-package21">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MemberAppPkg" type="radio" value="21"></span>
<span class="mn-form-name">
<span class="mn-memberapp-pkgname">Veteran Owned Business </span>: <span class="mn-memberapp-pkgfee"> $300.00 </span><br>
<span class="mn-memberapp-pkgdesc">Basic Membership with Veteran Discount | Proof of Veteran status is required</span>
</span>
</label>
<input id="NewMemberInfo_MembershipPackageFee" name="NewMemberInfo.MembershipPackageFee" type="hidden" value="0.00">
</div>
</div>
<div id="mn-memberapp-addonopt" class="mn-form-row">
<div class="mn-form-title">Additional Opportunities:</div>
<div class="mn-form-note">We will contact you with additional information.</div>
<div class="mn-form-combo mn-form-checkcombo">
<label id="mn-memberapp-addonopt1">
<span class="mn-form-field"><input type="checkbox" class="mn-form-check" name="NewMemberInfo.AddOns" value="1"></span>
<span class="mn-form-name">
<span class="mn-memberapp-addonname">Membership Plaque</span>
<span class="mn-memberapp-addonfee">: <span class="mn-memberapp-addonfeename">$0.00</span></span>
<br><span class="mn-memberapp-addondesc">Opt in to get a Member Plaque to showcase at your business or office! You will receive 1 white finished wood plaque with Black & Purple HWCOC Proud Member since (join date). Please Note:
Plaques will not be ordered nor delivered if the address is listed as a P.O. Box or Out of State.</span>
</span>
</label>
</div>
</div>
<div id="mn-memberapp-pmtopt" class="mn-form-row">
<div class="mn-form-title">Payment Option:</div>
<div class="mn-form-combo mn-form-radiocombo">
<label id="mn-memberapp-pmtoptBillMe">
<span class="mn-form-field"><input class="mn-form-radio" name="NewMemberInfo.MbrPmtOpt" type="radio" value="BillMe"></span>
<span class="mn-form-name">Bill me</span>
</label>
<label id="mn-memberapp-pmtoptCC">
<span class="mn-form-field"><input checked="checked" class="mn-form-radio" name="NewMemberInfo.MbrPmtOpt" type="radio" value="CC"></span>
<span class="mn-form-name">Charge my credit or debit card</span>
</label>
</div>
</div>
</div>
</div>
<div id="mn-memberapp-captcha" class="mn-section">
<div class="mn-section-content">
<div id="mn-memberapp-answer" class="mn-form-row">
<div class="g-recaptcha" data-sitekey="6LcpNUMUAAAAAB5iVpO_rzGG2TK_vFp7V6SCw_4s" data-callback="onReCaptchaSuccess">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LcpNUMUAAAAAB5iVpO_rzGG2TK_vFp7V6SCw_4s&co=aHR0cHM6Ly9idXNpbmVzcy5od2NvYy5vcmc6NDQz&hl=de&v=8G7OPK94bhCRbT0VqyEVpQNj&size=normal&cb=o22g920edgv"
width="304" height="78" role="presentation" name="a-gmdu9344ew58" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div><textarea id="g-recaptcha-response" name="g-recaptcha-response"
class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</div>
</div>
</div>
<div id="mn-memberapp-privacy-policy" class="mn-form-row mn-memberapp-privacy-policy" style="display:none">
<label>
<span class="mn-form-field"><input type="checkbox" id="mn-privacy-policy-chk" class="mn-form-check" onclick="javaScript: showPrivacyPolicy();"></span>
<span class="mn-form-name">I have read and accept the <a href="https://business.hwcoc.org/communication/privacypolicy" target="_blank" style="text-decoration: underline">privacy policy</a> of Houston West Chamber of Commerce. I grant Houston
West Chamber of Commerce permission to contact me regarding my account, news, updates, and offers.</span>
</label>
<div class="mn-error-summary" id="mn-memberapp-privacy-policy-error" style="display: none;">
<p> Please read and accept the privacy policy before continuing. </p>
</div>
</div>
<div class="mn-actions">
<ul>
<li class="mn-action-submit"><input type="submit" onclick="doSubmit();" class="mn-button" value="Submit Application"></li>
<li class="mn-action-print"><a href="https://business.hwcoc.org/member/NewMemberApp/?rendermode=print" rel="nofollow" onclick="return!MNI.Window.Print(this)" target="_blank">Print Application</a></li>
</ul>
</div>
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MEMBER APPLICATION
Home / Member Application
Thank you for your interest in joining the Houston West Chamber! APPLICATIONS
ARE PROCESSED IN 7 - 10 BUSINESS DAYS AFTER PAYMENT OF MEMBERSHIP DUES. Please
review membership levels by clicking the "Membership Benefits" button above.
Business Information
Company Name: *
Leave Blank:
Phone: *
Website:
Email: *
Business Description (500 char max):
Directory Category: * --- Select Primary Category --- ACCOUNTANTS/CERTIFIED
PUBLIC ADVERTISING/GRAPHICS ADVISORY BOARD AIR CONDITIONING & HEATING APARTMENTS
ARTS, AMUSEMENT & ENTERTAINMENT ASSISTED LIVING & RETIREMENT COMMUNITY ATTORNEYS
AUTOMOTIVE BAKERY & CAFES BANKS BEAUTY SALONS & SPAS BUSINESS BUILDER MEMBER
BUSINESS CONSULTANTS BUSINESS SERVICES CARPET & FLOORING CATERING, EVENTS &
VENUES CHAIRMAN'S CIRCLE MEMBER CHURCHES CLUBS & ORGANIZATIONS CONFERENCE CENTER
COURIER SERVICE CREDIT RESTORATION CREDIT UNIONS DENTAL SERVICES DIAMOND PARTNER
EDUCATION EMBROIDERY & SCREENPRINTING ENERGY PROVIDER ENGINEERING, CONSTRUCTION
& TECHNICAL SERVICES FINANCIAL LITERACY FITNESS CENTER FLORAL & SPECIAL
ARRANGEMENTS FUNERAL SERVICES GENERAL & ELECTRICAL CONTRACTORS GOLF CLUB
GOVERNMENT & ELECTED OFFICIALS GROCERY STORES HEALTH & WELLNESS HOSPITALITY
HOSPITALS & URGENT CARE FACILITIES HOTEL/MOTEL HR & PAYROLL IMPORT/EXPORT
INSURANCE INTERIOR DECORATING INVESTIGATIONS INVESTMENT & FINANCIAL SERVICES
IT/TECHNOLOGY JANITORIAL SERVICES/SUPPLIES JEWELRY LANDSCAPING LOCKSMITH
MANUFACTURERS & PROCESSORS MARKETING/PUBLIC RELATIONS MASSAGE THERAPY MEDICAL
SERVICES MEMORY & DEMENTIA CARE MORTGAGE COMPANIES MOVING NETWORKING
ORGANIZATION NON-PROFIT OFFICE SPACES OFFICE SUPPLIES/EQUIPMENT OIL & GAS
OPTOMETRY PACKING & SHIPPING PERSONNEL & STAFFING PHARMACY
PHOTOGRAPHY/VIDEOGRAPHY PLATINUM PARTNER MEMBER PLUMBING PRINTING & GRAPHICS
PROMOTIONAL PRODUCTS PUBLISHERS RADIO & TELEVISION REAL ESTATE Real Estate
REMEDIATION & SANITIZING RESTAURANT RETAILERS SECURITY SENIOR CARE SIGNATURE
SPONSOR SOCIAL MEDIA SPORTS STORAGE FACILITIES STUDIO/SHOWROOM
TELECOMMUNICATIONS TITLE COMPANY TRANSPORTATION TRAVEL AGENCY VETERINARY &
ANIMAL CLINICS WASTE MANAGEMENT/DISPOSAL WEB MARKETING WELLNESS & NUTRITION
WHOLESALE & DISTRIBUTORS
Employees: *
Full-time Part-time
Business Keywords (enter a space between words):
Comments / Questions:
Referred by:
Did a member of our staff assist you with your Chamber membership?: * Yes No
If so, Please indicate which member of our staff assisted you: * Kari Werner
Shawnda Peters Devyn Waggoner Monica Viveros Ashley Smith Jeffrey Reich-Hale No
staff member assisted me
How did you hear about the chamber?: *
Please select your top reason for joining: * Sales/Profit Visibility/Marketing
Networking Education/Seminars Ribbon Cutting Certificate of Origin Other
I give permission for the HWCOC to email/fax/mail info to my business: Yes No
I give permission to list my business on online directory: Yes No
Physical Address
Line 1: *
Line 2:
City: *
State: *
Postal Code: *
Country: * --- Select Country --- Afghanistan Albania Algeria Argentina Armenia
Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Belgium Belize Bermuda
Bermuda Bolivarian Republic of Venezuela Bolivia Bosnia and Herzegovina Botswana
Brazil Brunei Darussalam Bulgaria Cambodia Cameroon Canada Caribbean Chile China
Colombia Congo [DRC] Costa Rica Croatia Czech Republic Denmark Dominican
Republic Ecuador Egypt El Salvador Eritrea Estonia Ethiopia Faroe Islands
Finland France Georgia Germany Greece Greenland Guatemala Haiti Honduras Hong
Kong Hong Kong SAR Hungary Iceland India Indonesia Ireland Israel Italy Ivory
Coast Jamaica Japan Jordan Kazakhstan Kenya Korea Kuwait Kyrgyzstan Lao PDR
Latin America Latvia Liechtenstein Lithuania Luxembourg Macao SAR Macedonia
(Former Yugoslav Republic of Macedonia) Malaysia Maldives Mali Malta Mexico
Moldova Mongolia Montenegro Morocco Myanmar Nepal Netherlands New Zealand
Nicaragua Nigeria Norway Oman Pakistan Panama Paraguay Peru Philippines Poland
Portugal Principality of Monaco Puerto Rico Réunion Romania Russia Rwanda Saudi
Arabia Senegal Serbia Serbia and Montenegro (Former) Singapore Slovakia Slovenia
Somalia South Africa Spain Sri Lanka Sweden Switzerland Taiwan Tajikistan
Thailand Trinidad and Tobago Tunisia Turkey Turkmenistan U.A.E. Ukraine United
Kingdom United States Uruguay Uzbekistan Vietnam Yemen
MAILING ADDRESS
Same as physical address
Line 1: *
Line 2:
City: *
State: *
Postal Code: *
Country: * --- Select Country --- Afghanistan Albania Algeria Argentina Armenia
Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Belgium Belize Bermuda
Bermuda Bolivarian Republic of Venezuela Bolivia Bosnia and Herzegovina Botswana
Brazil Brunei Darussalam Bulgaria Cambodia Cameroon Canada Caribbean Chile China
Colombia Congo [DRC] Costa Rica Croatia Czech Republic Denmark Dominican
Republic Ecuador Egypt El Salvador Eritrea Estonia Ethiopia Faroe Islands
Finland France Georgia Germany Greece Greenland Guatemala Haiti Honduras Hong
Kong Hong Kong SAR Hungary Iceland India Indonesia Ireland Israel Italy Ivory
Coast Jamaica Japan Jordan Kazakhstan Kenya Korea Kuwait Kyrgyzstan Lao PDR
Latin America Latvia Liechtenstein Lithuania Luxembourg Macao SAR Macedonia
(Former Yugoslav Republic of Macedonia) Malaysia Maldives Mali Malta Mexico
Moldova Mongolia Montenegro Morocco Myanmar Nepal Netherlands New Zealand
Nicaragua Nigeria Norway Oman Pakistan Panama Paraguay Peru Philippines Poland
Portugal Principality of Monaco Puerto Rico Réunion Romania Russia Rwanda Saudi
Arabia Senegal Serbia Serbia and Montenegro (Former) Singapore Slovakia Slovenia
Somalia South Africa Spain Sri Lanka Sweden Switzerland Taiwan Tajikistan
Thailand Trinidad and Tobago Tunisia Turkey Turkmenistan U.A.E. Ukraine United
Kingdom United States Uruguay Uzbekistan Vietnam Yemen
Social Networking:
LinkedIn Facebook Twitter You Tube Yelp Instagram
Primary Contact Information
First Name: *
Last Name: *
Title:
Phone: *
Cell Phone:
Fax:
Email: *
Contact Preference:
Email Phone
ADDRESS
Same as Member Address
Line 1: *
Line 2
City: *
State: *
Postal Code: *
Country: * --- Select Country --- Afghanistan Albania Algeria Argentina Armenia
Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Belgium Belize Bermuda
Bermuda Bolivarian Republic of Venezuela Bolivia Bosnia and Herzegovina Botswana
Brazil Brunei Darussalam Bulgaria Cambodia Cameroon Canada Caribbean Chile China
Colombia Congo [DRC] Costa Rica Croatia Czech Republic Denmark Dominican
Republic Ecuador Egypt El Salvador Eritrea Estonia Ethiopia Faroe Islands
Finland France Georgia Germany Greece Greenland Guatemala Haiti Honduras Hong
Kong Hong Kong SAR Hungary Iceland India Indonesia Ireland Israel Italy Ivory
Coast Jamaica Japan Jordan Kazakhstan Kenya Korea Kuwait Kyrgyzstan Lao PDR
Latin America Latvia Liechtenstein Lithuania Luxembourg Macao SAR Macedonia
(Former Yugoslav Republic of Macedonia) Malaysia Maldives Mali Malta Mexico
Moldova Mongolia Montenegro Morocco Myanmar Nepal Netherlands New Zealand
Nicaragua Nigeria Norway Oman Pakistan Panama Paraguay Peru Philippines Poland
Portugal Principality of Monaco Puerto Rico Réunion Romania Russia Rwanda Saudi
Arabia Senegal Serbia Serbia and Montenegro (Former) Singapore Slovakia Slovenia
Somalia South Africa Spain Sri Lanka Sweden Switzerland Taiwan Tajikistan
Thailand Trinidad and Tobago Tunisia Turkey Turkmenistan U.A.E. Ukraine United
Kingdom United States Uruguay Uzbekistan Vietnam Yemen
Billing Contact Information
Same as Primary Contact
First Name: *
Last Name: *
Title:
Phone: *
Cell Phone:
Fax:
Email: *
Contact Preference:
Email Phone
ADDRESS
Same as Member Address
Line 1: *
Line 2
City: *
State: *
Postal Code: *
Country: * --- Select Country --- Canada United States
Membership Options
Membership Package: *
Basic Membership (Yearly): $400.00
Business Builder: $755.00
Ribbon Cutting and Certificate of Origin Chairman's Circle (1-Yr): $1,995.00
Chairman's Circle (2-Yr): $3,595.00
Platinum Partner (1-Yr): $3,995.00
Platinum Partner (2-Yr): $7,195.00
Non-Profit Membership: $300.00
Proof of 501(c)3 status is required. Veteran Owned Business : $300.00
Basic Membership with Veteran Discount | Proof of Veteran status is required
Additional Opportunities:
We will contact you with additional information.
Membership Plaque : $0.00
Opt in to get a Member Plaque to showcase at your business or office! You will
receive 1 white finished wood plaque with Black & Purple HWCOC Proud Member
since (join date). Please Note: Plaques will not be ordered nor delivered if the
address is listed as a P.O. Box or Out of State.
Payment Option:
Bill me Charge my credit or debit card
I have read and accept the privacy policy of Houston West Chamber of Commerce. I
grant Houston West Chamber of Commerce permission to contact me regarding my
account, news, updates, and offers.
Please read and accept the privacy policy before continuing.
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CONTACT
* 10375 Richmond Ave. Suite 265 Houston, TX 77042 located at the Millennium
Tower
* info@hwcoc.org
* 713-785-4922
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