Your Name _____________________________________________

Your Title _______________________________________________

Company or Agency name ______________________________________________

Company Type ( ) Sole Proprietor / Business Owner
( ) For-Profit Corporation
( ) Non-Profit Corporation
( ) None (ie - employee or community member)

Street Address ____________________________________________

City _________________________________

State _______ Zip __________

Day Phone ________________________

Cell/Night # ________________________

FAX number _______________________

Email Address _____________________________________________

Website Address (if any) _____________________________________________

Annual Membership Dues - One dues and one vote per company

Business ( ) 1-10 Employees ($75)
( ) 11-or more Employees ($100)

Non-Profit ( ) 1-10 Employees ($50)
( ) 11-or more Employees ($75)

( ) Community member or Non-administrative employee - $50


Please print and mail this completed form with your check made payable to
Greater El Sereno Chamber of Commerce
4207 Maycrest Ave, Los Angeles, CA 90032