Referred By

Company Name

Primary Contact

Title

Phone

Email

Cell Phone

Fax

Website

Business Type

Address

Zip

Reason for Joining

Number of Employees

Federal ID Number

Membership Structure Membership StructureTrustee Advisor - Business $550 (2) Two MembersParticipating Business Member $250 (Additional Member $200)Government / Non-Profit - Associate $200 (Additional Member $175)Individual $100Student $25

Participating Business (Annual membership dues are based on the number of full time employees employed with the company as follows) Participating Business (Annual membership dues are based on the number of full time employees employed with the company as follows)1-5 $2506-10 $27511-25 $35026-50 $42551+ $10/employee (max $3,000)Affiliate $200/per affiliated location (after initial company payment)Chairman’s Council $ 5,000 (for more information please contact the BGCC at 786-486-7217)

BGCC Foundation Committee Donation (please indicate one time donation amount)