Pay by Credit or Debit Card

A 3% convenience fee will be applied.  This fee may be avoided by paying by check.

Company Name *

Contact Person & Title *

Street Address *

Street Address Line 2

City *

State / Province / Region *

Zip Code *

Phone *

Email Address *

Included Email in Online Directory? *

YesNo

Website Address

Business Description (up to 80 characters)

The information below will not be released to the public, but it will help PPBIC deliver important information (safety alerts, emergencies, relevant meetings, etc.) to the appropriate people.

Number of Full Time Employees *

Number of Part Time Employees *

Main Contact Name, Telephone, and Email Address if Different from Above

Facilities Manager Name, Telephone, and Email Address if Different from Above

HR Manager Name, Telephone, and Email Address if Different from Above

Please Select Your Membership Type:

Business with 51+ Employees - $450Business with 13-50 Employees - $330Business with 4-12 Employees - $200Business with 1-3 Employees - $125Bank - $330Non-Profit or Restaurant - $125

3% Convenience Fee

Total Balance Due

Credit / Debit Card *

SUBMIT APPLICATION & PAYMENT