Membership Application Form Online

Please fill out this form for membership with the Southtown Council. After successfully submitting the completed form, you'll be given the chance to pay your membership dues online through PayPal. If you do not wish to use this secure efficient online payment service please forward your check to the Southtown Office.

Date:

Name of Business: *

Address of Business - Street: *

City: *

State: *

Zip: *

Mailing Address (if different):

Telephone Number: *

Fax Number:

E-Mail Address: *

E-Mail Address (confirm): *

Name of Business Owner: *

Name of Business Manager:

Business Description: *

Please describe the nature of your business (what you sell or service you offer) and the hours of operation. Your business may be featured in the Southtown Council's monthly Newsletter in the future as space permits.

Payment Form: *

1st year membership dues are currently set at $65.00

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Math question: * 4 + 5 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

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