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Membership Rewards

Business & Merchant Application  

COMPANY INFORMATION:

Company Name:__________________________________________________________________

Company Representative:__________________________________Title:_____________________________

Street/Box:_______________________________________________________________________

City/Town:__________________________________________ State:______Zip:______________

Physical Location:_________________________________________________________________

Work:______/______/_________Fax:______/______/________

Rep Email:___________________________________________

Company URL: www.______________________________________________________________

Type of Business:_____________________________

INCENTIVE INFORMATION:

[  ] Discount ______%   [  ] Gift _____________________  [  ]  Other ______________________

Proposed Restrictions: _____________________________________________________________

Notes:  _________________________________________________________________________

CERTIFICATION:

I hereby apply for membership in the Fairfield Chamber of Commerce “Rewards” Program and agree to abide by all the rules and regulations thereof. I understand that I may enter or leave the program at any time with 60 days written notice. I understand that my membership and incentive offer is subject to approval by the Chamber; that the Chamber will not be liable for misunderstandings or problems arising from my participation and my membership can be revoked if I fail to comply with the guidelines or spirit of the Program.

Signed:_________________________________________________Date: _____/______/_______

Print Name:____________________________________________________________