Premier Membership Application

Business Details

Business Name *

ABN *

Number of Employees *

Physical Address *

Address Line 1

Address Line 2

City

State / Territory

Post Code

Postal Address (If different to above)

Address Line 1

Address Line 2

City

State / Territory

Post Code

Phone

Business Logo *

Click or drag a file to this area to upload.

Primary Contact

Name *

Position in the business *

Email *

Phone *

Email (accounts & invoicing) if different to above

Please provide a short description of the primary purpose of your business *

Newsletter Subscription

Representative 1

Name *

Job Title *

Email *

Representative 2

Name

Job Title

Representative 3

Name

Job Title

Representative 4

Name

Job Title

Representative 5

Name

Job Title

Representative 6

Name

Job Title

Member Declaration

Declaration *

Yes, I agree *

I/We give my permission for this information to be included on the database and online directory.

I/We give permission to EKCCI to use and publish my photographs for promotional use.

I/We agree to abide by the Constitution and rules of the Chamber.

On behalf of the above-mentioned business/organisation & representatives, I/we agree to the conditions of Membership as presented to me.

EKCCI is committed to handling your contact information in accordance with Commonwealth and State Privacy Laws. To ensure our practices comply.

I/we agree to receive newsletters, event invitations and special offers from EKCCI

(You may opt out of any of these services at any time by contacting EKCCI directly.)

Tax Invoice

If you would prefer a tax invoice to pay via direct debit please tick here.

East Kimberley Chamber of Commerce

PO Box 171 Kununurra WA 6743

Telephone:

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