Become a Member – Sign Up Using Our Membership Form 2021 Membership Form Date Legal Business Name * Owner * Trade Name Manager Type of Business Mailing Address (Town Postal Code) * Mailing Address (Town Postal Code) Mailing Address (Town Postal Code) Mailing Address (Town Postal Code) City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic 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City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Phone Number(s) * Email ***This will be shown on the Blackfalds Chamber website directory. * Website Physical Address Physical Address Physical Address Physical Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Membership Fee Schedule - 2021 By checking off this box you agree to payment before becoming a member of the Blackfalds Chamber. * Yes I agree New Member June 30, 2021 – June 30, 2022 $100 No GST **Annual Fee if Monthly Payment Plan (Chamber Group Benefits members only) $120 **Note: Members must participate in the Chamber Group Insurance Plan in order to have the option of monthly payments. Payable by Email Interac, cheque (Payable to: Blackfalds & District Chamber of Commerce), MasterCard, or Visa. Please send payment with completed application. PAYMENT OPTIONS: etransfer Email blackfaldschamber@outlook.com Cheque Payable to Blackfalds & District Chamber of Commerce MasterCard or Visa – Phone (403)506-6735 0l> Check the box that are appropriate * Would you be interested in the Chamber Group Insurance Plan? I would like to occasionally volunteer with Chamber events or committees. I would like to receive updates from the Chamber through newsletters or emails. CHECK (√) THIS BOX IF YOU DO NOT WISH TO HAVE YOUR BUSINESS CONTACT INFORMATION INCLUDED in business listings, lists or directories which may be distributed, published, emailed or posted on the internet or other Chamber publications. This Information is collected under the authority of the Freedom of Information and Protection of Privacy Act. In addition, business contact information including individual’s contact name, address, telephone # and email address may be disclosed by the Chamber upon request unless it reveals personal or third party information. Members must pay their fee no later than 60 days after the due date before they are removed from active membership status. ***For office use only*** Payment Details: Annual / Monthly Type of Payment Recieved: Date Received of Payment: Receipt Issued - Initial: Added to Mailing List - Initial: Website/URL If you are human, leave this field blank. Submit