Business Membership Form

BUSINESS MEMBERSHIP
Please print this form and mail to PCDC PO Box 222 Carmel, NY 10512 or register online.

Name of Business __________________________________________________
Address _________________________________________________________
Contact Person ____________________ website __________________________
Email ____________________________ Business Phone ____________________
Business FAX _____________________ Cell ____________________________

Please fill in one box for each employee ( up to 15 employees plus yourself)

Each will receive a welcome packet describing benefits

Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________	Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________
Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________	Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________
Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________	Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________
Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________	Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________

Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________	Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________
Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________	Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________
Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________	Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________
Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________	Last Name ________________________ Wife's Name ______________________ Husband Name ____________________ address __________________________ ________________________________ Phone ___________________________ email ____________________________