Application

Organization Information (to be displayed online)

Organization Name

Address 1

Address 2

City

State

Zip

Phone

Fax

Website

Main Contact

Salutation

First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

Additional Contacts

Contact 1

First Name

Last Name

Title

Email Address

Contact 2

First Name

Last Name

Title

Email Address

Contact 3

First Name

Last Name

Title

Email Address

Contact 4

First Name

Last Name

Title

Email Address

Contact 5

First Name

Last Name

Title

Email Address

Contact 6

First Name

Last Name

Title

Email Address

Contact 7

First Name

Last Name

Title

Email Address

Contact 8

First Name

Last Name

Title

Email Address

Contact 9

First Name

Last Name

Title

Email Address

Contact 10

First Name

Last Name

Title

Email Address

Billing Address (if different)

Address 1

Address 2

City

State

Zip

Mailing Address (if different)

Address 1

Address 2

City

State

Zip

Additional Information

Referred By

How did you hear about us?

What is your reason for joining?

Please have someone contact me regarding

Business Resources
Community Involvement
Cost Savings Programs (Insurance, Office Supplies, Worker's Compensation)
Economic Development
Government Relations
Networking
Other

Directory Short Description

Directory Long Description

Membership Investment

Primary Directory Category

Additional Directory Categories

Select additional directory categories below by holding the "CTRL" key
Additional directory categories are $100 each, to be billed separately from membership dues. A DSCC representative will contact you should you choose to have additional categories assigned to your organization.

Number of Full Time Employees

Because your company size is in excess of 250 employees, we cannot proceed with the ONLINE Membership Application at this time. Instead, please contact Ken Evans at [email protected] or 302-576-6576 to find out what your negotiated rate would be. Thank you.

Annual Membership Investment

Total

The contents of this box are for testing purposes. This box will be removed when the form goes live.

Membership Type

Number of Part Time Employees

Number of Rooms

Number of Seats

Number of Associates

Number of Locations

Millions in Assets

Enhanced Membership ($50)

Additional Items

Additional Categories Cost

One-Time Application Fee

Tax

Full-Time Employees

Part-Time Employees

Hotel/Motel Rooms

Restaurant Seats

Additional Associates

Additional Associates Cost

Additional Locations

Additional Locations Cost

Assets

Assets Cost

Additional Categories

Number Of Additional Categories

Additional Categories Cost

Additional Item 1 Cost

Additional Item 2 Cost

Additional Item 3 Cost

Additional Item 4 Cost

Additional Item 5 Cost

Additional Item 6 Cost

Additional Item 7 Cost

Additional Item 8 Cost

Additional Item 9 Cost

Additional Item 10 Cost

Annual Dues (charged to card)

Revenue Item

Tax (charged to card)

Fee (charged to card)

Temp Value For DropDown 1

MembershipType

Additional Item 2

Additional Item 3

Additional Item 4

Additional Item 5

Additional Item 6

Additional Item 7

Additional Item 8

Additional Item 9

Additional Item 10

Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Credit Card Information

Credit Card Type MastercardVisaDiscoverAmex

Credit Card Number

Name on Card
Security Code
Valid Through
Address
City
State
Zip
Phone
Credit Card Email Address

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Please make all required responses before submitting your application.

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