KEDC Membership Pledge Card

Kern EDC Membership Pledge Card

Company Name*

(As you would like it listed in marketing collateral)

Business Classification*

What does the company specialize in?*

Website*

Company Phone Number *

(To be listed in public Member Index)

Company Primary Contact*

First Name

Last Name

Primary Contact Title*

Primary Contact Phone*

Primary Contact Email*

Company Secondary Contact *

First Name

Last Name

Secondary Contact Title *

Secondary Contact Phone*

Secondary Contact Email*

Membership Level*

* Active is for companies with fewer than 25 employees

Preferred Payment Schedule*

Pay Annually Pay Semi-Annually (Invoice only) Pay Quarterly (Invoice only)

***If you select Semi-Annually or Quarterly, please request to be invoiced. First year of Membership must be paid in full then payments can be Semi-Annually or Quarterly.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Payment Information

Total* $

Select payment option*

Credit Card I would like to be invoiced

Mailing Address (To be listed in public Member Index)*

Address Line 1

Address Line 2

City

State

ZIP Code

Name on Credit Card*

Credit Card Number*

Billing Address (if different from mailing address)

Address Line 1

Address Line 2

City

State

ZIP Code

Attention invoice to*

First Name

Last Name

Send invoice to following email address*