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MDHCC Membership Application
 
Please complete all fields below. After completing the form below, please select whether you will be paying via Paypal (including Credit Card) or via Check.
Primary Applicant: Please enter the main contact for the Organization.
Last Name:
 		First Name: Middle Name:
Title:
Business: Please enter the main Business information.
Name of Organization:
Department/Division:
Address: Please enter the primary address for the Organization.
Street:
 Apt/Suite:
City:
State:
 Zip Code:
 County:
Contact: Please enter your contact information.
Phone:
 Fax:
 		Mobile:
Website:
 Email:
Type of Business: Please indicate your primary line of business.
 

Retail, Restaurants, Real Estate, Services
High Technology
Banking, Financial Services, Insurance
Media & Entertainment
Professional (Physician, Attorney, Accountant, etc.)
Government Agency
Health Care, Education
Construction/Remodeling
Consultant Services
Government Contractors
Chamber of Commerce, Non-Profits
Other:

Membership Dues: Please select your Membership type.
 

Professional/Individual ($100)
Small Business: 3-10 Employees ($200)
Mid-Size Business: 11-30 Employees ($300)
Large Business: 30+ Employees ($500)
Corporate Bronze: ($1,000)
Corporate Silver: ($2,000)
Corporate Gold: ($4,000)
Corporate Diamond: ($6,000)
Corporate Platinum: ($10,000)


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Maryland Hispanic Chamber of Commerce | 20300 Century Blvd., Suite 175 | Germantown, MD 20874
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