Rice Lake Chamber Membership

Business / Organization Name

Name

First Last

Contact Title

Business Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address / PO Box (if different from above)

Street Address Address Line 2 City State ZIP Code

Phone Number (Day)

Alternate Phone

Email

Website

Other contact names, phone and email

Contact Name	Phone	Email

Will not be listed in marketing materials

Please describe your business

If Other - Please describe

Please check which events you are interested in volunteering for

Please upload your company logo

Bio/About Your Company

Please Select Type of Membership

Payments*

Check Payment

Please remit all checks to:
Rice Lake Area Chamber of Commerce
37 S Main St, Rice Lake, WI 54868-2299

Credit Card Payment

Do you want to cover the payment transaction fees?

Yes, I would like to cover the payment transaction fees

Credit Card Payment Transaction Fees

Price: $0.00

Credit Card

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Visa

Card Number Expiration Date Security Code Cardholder Name

Consent and Release Forms

Date*

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Rice Lake Chamber of Commerce, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet).

This consent includes, but is not limited to: (select where applicable)*

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
(b) Permission to use my name; and
(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

Please uncheck any items that you are not agreeing to.

Are you signing for a minor?

Yes
No

Name of Minor

First Last

Address of Minor

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Parent or Legal Guardian

First Last

The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.

Signature of Parent or Legal Guardian:

Subtotal

$0.00

Signature

Phone

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Rice Lake Chamber Membership

Rice Lake Chamber of Commerce - Membership 2020

Check Payment

Credit Card Payment

Consent and Release Forms