Application for Membership
Space Coast Business Guild

Name: ______________________________________________________________

Business Name: ______________________________________________________

Business Phone: ______________________________________________________

Personal Phone: _______________________________________________________

Address: _____________________________________________________________

City: _____________________ State: _______ Zip: _______________

Email: _______________________________________________________________

Briefly describe your business below:

____________________________________________________________________

____________________________________________________________________

How did you find out about the Space Coast Business Guild?

Word of Mouth - Print Advertising - Internet - Other: ________________________

If from current member, who? ___________________________________________

Method of payment Cash Check Credit Card       

SCBG Membership - $50 per year
Include an image   - $10 per year

Email your camera ready image (business card, logo, headshot, etc.)
 to menna@cfl.rr.com. Dimension can be no larger than 300 x 100 pixels at 72 dpi. 
We reserve the right resize your image.

Name as it appears on card: ____________________________________________

Credit Card #: _______________________________________________

Expiration date: ________________ CCV # (3 digit code on back) ______________

Signature: _____________________________________

Please print and complete.
Mail to: P.O. Box 562773 Rockledge, FL 32956
Fax to: 321-635-6078

For information, please contact:  Jason Rivera 321-591-1865
                                              Email:  spacecoastguild@cfl.rr.com

Keep up to date on activities and interact with members.
To join our Yahoo Group, visit http://finance.groups.yahoo.com/group/spacecoastbusinessguild/

www.spacecoastbusinessguild.org