Street Adress:__________________________________________
City:______________________________ Zip:________________
Mailing Adress:_________________________________________
(If different )
________________________________________
Telephone__________________________
Fax:_______________________________
Company Representative:__________________________________
Title:______________________________
Email:_____________________________
Type of Business:_________________________________________
Number of Employees:____________
Annual Dues $____________
Enrollment Fee $ 30
Total Amount $____________
Authorized Signature_______________________________________
Date______________________________
Sponsor___________________________
Makes check payable to : East Los Angeles Chamber of Commerce
P.O. Box 63220, Los Angeles 90063