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Name of Company *

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Primary Contact Person

Salutation

Name *

Title *

Nickname

Email Address *

Secondary Contact Person

Salutation

Name

Title

Nickname

Email Address

Other Information

Phone Number *

Extension

Fax Number

Cell Number

Web Site Address

About Your Business

Year Established

NAICS (SIC) Code

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NAICS (SIC) Description

Nature of Business

Total # of Employees

Total # of Employees in Columbia County

Business Description

Please describe your business in 25 words or less

SKU: 100 Category:

Additional information

Investment Amount:

Sustaining Membership: $2500+, Full Membership: $750-$2499, Associate Membership: $250-$749, MicroBiz Membership: $125-249