Join Us Join the Bridgeport Regional Business Council today! Membership Application (pdf) Business and Contact Information *Name of Business: *Address: *City: *State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico *Zip: *Phone: Fax: Web Site: *Key Contact First Name: *Key Contact Last Name: Title: *E-mail: Additional Contact Name: Title: E-mail: *Full Time Employees: *Part Time Employees: *Business Category Advertising: Marketing, Media, Promotion Automotive, Aviation, Marine & Trucks Business & Professional Services Employment & Staffing Finance & Banking Services, Insurance Government & Educational Organizations Health Care Home & Garden Individuals Lodging & Entertainment Personal Services, Shops & Retail Production, Manufacturing, Industrial Public Utilities, Environment, Fuel Real Estate & Construction Restaurants, Catering, Beverages Social Service & Non Profits Year Established: Sales Volume: Referral's Name: *Annual Membership Dues: *One time processing fee: PLEASE NOTE: Membership is continuous unless cancelled in writing. For federal income tax purposes, a portion of your investment is deductible as an ordinary and necessary business expense and not as a charitable contribution. The non-deductible portion of your Investment is 18%. Your investment covers one business location. Payment Information Pay By Credit Card Check Credit Card Type Mastercard Visa Amex Credit Card Number Name On Card Security Code Valid Through 01 02 03 04 05 06 07 08 09 10 11 12 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Use Address Above Credit Card Address 1 Credit Card City Credit Card State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Credit Card Zip Credit Card Phone Number Credit Card Email Address Please click submit only one time. The transaction may take several seconds.