2010 New Member Application

Please complete the application below and pay the $100 membership fee with your credit card. Your business profile will be automatically added to our online business directory and your email address will be added to our distribution list.
 
The form requires that you complete the fields marked with a red asterisk. If you would like to prevent your name, address, phone number, or email address from appearing on our website, simply check the 'hide' checkbox next to the appropriate field. You can choose up to two categories for your business. This information will be used to create your online business listing. You can always log into our Member's Only section at a later date and update your profile.
 
Please click the button on the bottom of the form once you are done.
Login Information
*Username
*Password
 
Names
*Business Name
*Contact Name Hide?
 
Address
Hide this address?
Street 1
Street 2
City, State, Zip ,
 
Phone Numbers
*Primary Phone Hide?
Alternate Phone
Toll Free Phone
Cell Phone
Fax Number
 
Other
Please contact Webmaster@Belleville-WI.com if you would like a new category added to the drop-down list.
Business Category #1
Business Category #2
Email Hide?
Website
Hours
 
Business Description
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