Membership Form

Triad Local First Membership Form
Mail with Payment:   1805 Pembroke Drive Greensboro, NC 27408
(or print and bring to any of our Membership Meetings)

Membership Levels
Catalyst $2,500
Champion $1,000
Business Membership $150 (add $25 for each additional location)
Local Supporter $50
Donation/Other $____

Name of Business____________________________________________________

Owner’s Name_______________________________________________________

Address____________________________________________________________

City______________________________State_________Zip_________________

Phone #_________________________

Email Address_______________________________________________________

Web Site___________________________________________________________

Type of Business ____________________________________________________

Type of Payment* ___________________________________________________
*Cash, check or credit card maybe be used.  We currently cannot accept American Express.

Totaly Payment Amount _______________________________________________

Billing Address ______________________________________________________