Member Application

Welcome to the Heartland Black Chamber of Commerce! We’re excited to learn more about you and your business. This application helps us understand your background, goals, and current needs so we can connect you with the right resources, networking opportunities, and programs. Please answer as accurately as possible, your information will help us better serve you and our community.

Step 1:

Member Info

Company Name *

Please add your company name.

Phone *

Please add your company phone number.

Website

Email *

Please add a valid email.

Physical Address

Address line 1

Address line 2

Country

City

State

Postal Code

Step 2:

Additional Info

Business Description (200 char max) *

Please add your company description.

Directory Category *

Please select a directory category.

Full-time Employees *

Please add your number of full-time employees.

Part-time Employees *

Please add your number of part-time employees.

Minority Business Status *

Looks good!

Ethnicity *

Looks good!

Years in Business *

Looks good!

Annual Revenue Range *

Looks good!

Business Needs

Business Need #1 *

Looks good!

Business Need #2 *

Looks good!

Business Need #3 *

Looks good!

Scopes of Work/Services Provided *

Looks good!

Licenses/Certifications *

Looks good!

Biggest Business Challenge *

Looks good!

Step 3:

Primary Contact

First Name *

Please add your first name.

Last Name *

Please add your last name.

Title

Phone *

Please add your phone number.

Email *

Please add a valid email.

Contact Preference

Phone

Step 4:

Billing Contact

Same as Primary Contact

First Name

Last Name

Title

Phone

Contact Preference

Phone

Step 5:

Membership Package

Please select a Membership Package

Membership Consultation

We’ll connect with you to learn more about your business and recommend the membership package that best fits your goals and needs.

Please complete the Captcha

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