Member

Business Information

Company Name: *

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Phone: *

Website: *

Email: *

Business Description (200 char max):

Directory Category: *

Employees: *

Full-time Part-time

Business Keywords (enter a space between words):

Comments / Questions:

Who referred you?:

Physical Address

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Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

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Line 2:

City: *

State: *

Postal Code: *

Country: *

Social Networking:

LinkedIn Facebook

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Social Networking:

LinkedIn Facebook

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Additional Fees:

Admin Fee : $30.00
One time administrative fee

Additional Opportunities:

We will contact you with additional information.

Kauai Military Affairs Support : $100.00
For an additional $100, I would like to support the Kauai Military Affairs Council (KMAC). By doing so, I would like to receive news and updates from the KMAC, along with exclusive invitations to Kauai Military and Veterans events.

Payment Option:

Charge my credit or debit card

Member Application

Mailing Address

Address

Address