BUSINESS NAME: ________________________________________________

ADDRESS FOR COMMUNICATION AND BILLING: _______________________________

_____________________________________________________________________________

CITY______________________ STATE______ ZIP______________

PHONE #_______________ FAX #______________ E-MAIL __________________

WEBSITE: _________________________________________________

TYPE OF BUSINESS: ________________________________________

NUMBER OF EMPLOYEES: FT__________________ PT_________________

ANNUAL INVESTMENT: ____________________________

AMOUNT REMITTED: ______________________________

INVESTMENT RENEWED ANNUALLY: JANUARY ______ or JULY _____

AUTHORIZED SIGNATURE: ______________________________________

CONTACT PERSON: _____________________________________________ (Print)

DATE: ___/___/___

Please print out and return this investment pledge with payment to:

Alleghany Highlands Chamber of Commerce
241 W. Main Street
Covington, VA 24426

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