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Organization Information (to be displayed online) Organization Name Address 1 Address 2 City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Phone Fax Website Email Main Contact Copy from Organization-Information First Name Last Name Address 1 Address 2 City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Title Phone Email Additional Contacts Add/Remove Contacts Contact 1 First Name Last Name Title Email Address Contact 2 First Name Last Name Title Email Address Contact 3 First Name Last Name Title Email Address Contact 4 First Name Last Name Title Email Address Contact 5 First Name Last Name Title Email Address Contact 6 First Name Last Name Title Email Address Contact 7 First Name Last Name Title Email Address Contact 8 First Name Last Name Title Email Address Contact 9 First Name Last Name Title Email Address Contact 10 First Name Last Name Title Email Address Billing Address (if different) Address 1 Address 2 City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Mailing Address (if different) Address 1 Address 2 City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Additional Information Keywords Areas of Interest Business Assistance Information Economic Development Government Networking Events Special Events AchieveHERs Tourism CYP I understand that by providing my mailing address, e-mail address, telephone number and fax number, I consent to receive communications sent by or on behalf of the AMPLIFY Clearwater (and its affiliates and subsidiaries) via regular mail, e-mail, telephone and/or fax. Membership Investment Membership Type Select one... Discover - $456 Empower - $1,100 Propel - $2,750 Magnify - $5,500 Amplify - $11,000 Add RGA Primary Directory Category None Accountants/Certified Public Accounting AchieveHERs Acupuncture Adjuster Adjuster - Public Insurance Adjuster/Loss Consultant Advertising Advertising - Directory & Guide Advertising/Agencies Advertising/Cable Advertising/Direct Mail Advertising/Online Advertising/Outdoor Aerial Photography Aerospace Technical Consulting Aesthetics Age Management Agriculture/Fertilizer Air Charters Air Conditioning/Heating Air Duct & Dryer Vent Cleaning Air Express Services Air Purification/Filtration Aircraft Sales & Service Airline Companies Airports Aluminum Products Animal Sanctuary Animal Shelter Annuities Answering Service Apartments/Townhomes Apparel Apparel Corporate Appliance Repair Appliances/Retail Architects Architectural Measuring Service Art & Framing Art Galleries Artist/Fine Art/Portraits Arts & Crafts Arts Centers/Museum Asset Recovery Assisted Living Facilities Associations Associations - Military ATM Cash Machines Attorneys - Bicycle Accident Injury Attorneys - Business Law Attorneys - Criminal Defense Attorneys - Eminent Domain Attorneys - Employment Law Attorneys - Estate Planning/Wills Attorneys - Family Law Attorneys - General Practice Attorneys - Immigration Attorneys - Insurance Law Attorneys - Intellectual Property Law Attorneys - Litigation Attorneys - Marital Attorneys - Personal Injury Attorneys - Probate Attorneys - Property/Real Estate Law Attorneys - Securities Disputes Attractions/Amusement Audio/Video Auditors Auto Accessories Auto Clubs Auto Glass Auto Parts & Supply Wholesale Auto Rental/Leasing Auto Repairs Auto/Boat Detailing & Customizing Automobile Dealer/Used Automobile Dealer/Warranty/Brokers Automobile Oil Change Automobile Wash & Wax Automotive Services Aviation Avionics Awards Awnings Background Checks Bail Bonds Bakeries Bank Consultants Banks Bar/Pub Barter Exchange Bath Accessories/Whirlpools Bathroom Renovations Batteries Beach Concessions Beach Rentals Bed and Breakfast Bedbug Detection Beer/Wholesale/Retail/Brewery Beverages/Bottlers Bicycle Dealer/Rentals Bingo Centers Bio Hazardous Services Blind Services Blood Banks Boat & Jet Ski Dealers/Service/Storage Boat Club Boat Renting & Leasing Boating Instruction Boats Book Dealers Bookkeeping Service Bowling Lanes Brand Name Incentives Brewery Bridal Boutique Broad Band Solutions Building Plans Bus Charters Business & Personal Coaching Business Brokers Business Cards & Post Cards Business Coaches Business Consultants Business Counseling Business Records Destroyed Business Services Business Software Solutions Cabinet Makers Cable Installation Cable Television Campgrounds Cancer Treatment Candles Candy Manufacturing Canoe/Kayaks Carpet Cleaning Carpets/Retail Carpets/Wholesale Cash Register Systems Caterers CD Rom Marketing Chambers of Commerce Charitable Foundation Charities Charter Boats Check Cashing Check Manufacturer Check Protection & Signing Machines Child Care/Preschool/Nursery Schools Children's Program Chiropractors Christmas Stores Churches Cigars Civil Engineering Cleaners & Laundries Cleaning Services Clinics/Medical Clothing-Retail/Wholesale Coffee Distributors Coin Dealers Collection Agencies Commercial Building Control Systems Commercial Transport Communication Services Community Center Community Organization Community Service Computer Consultant/Training Computer Sales/Service Computer Software Developer Computer Software/Hardware/Service/Supplies Computer Systems/Service Computer Technology/Management Services Computer/Internet Solutions/Consulting Computers - Wireless Networks Concessions Condominium Rentals Condominium/Developer Condominiums Congregate Living Consignment Shops Construction Commercial & Residential Construction Consultants Construction Management Construction/Undergroud Utilities Consultants Consumer Protection Contractor/Auto Glass Contractor/Referral Service Contractors/Building Contractors/General Convenience Store Convention/Banquet Facility Cookware Copier/Facsimile Machines Copy Machine/Sales & Services Copy Service Corp Office - Hospitality Cosmetics Counseling & Support Services Countertops Country Clubs Court Reporter Credit Card Processing Credit Counseling Credit Union Cruise Lines Currency Exchange Custom PowerPoint Presentations Dance Instruction Dance Studio Data Processing Data Services Database Managment Dating Service Day Spa Debt Management Decorative Surfaces Delicatessen Delivery Service Dental Clinics Dental Equipment/Sales/Service Dental Insurance Dental Lab Dentist Department Stores Dermatology Design/Builders Dialysis Outpatient Digital Advertising Direct Mail Disability Services Disaster Relief Disc Jockey/Concert Promotions Displays/Exhibits/Store Fixtures Diving Instruction Divorce Mediation Services Document Imaging Donation Center Draperies Drug Detection & Testing Drug Rehabilitation Dry Ice Economic Development Services Education Educational Consulting Electrical Contractor Electrical Equipment & Service Electronic Components Electronic Distributor & Manufacturer Elevators Embroidery Employee Benefits Employee Development Employee Leasing Employment Agencies/Services Employment Agencies/Temporary Employment Screening Energy Saving Devices Engineering Engineering/Ergonomics & Safety Engineers/Consulting Engravers Entertainment Entertainment Agencies Environment Environmental Consultants Equipment Leasing Equipment-Restaurant/Service/Design Equity Savings Program Event Marketing Consultants Event/Meeting Planning Excavating Facilities Management Family Services Farmer Market Fashion Design Film Processing/Production Film/Industrial & Commercial Financial Advisor Financial Consultants/Planners/Services Financial Services Financing Fingerprinting Fire Alarm Systems Sales & Service Fire/Water Restoration Firearms Fireworks Display Fishing Parties/Charters Fitness & Recreation Centers Flags & Banners Flooring Florists/Retail Food Distributors Forensic CPA Foster Care/Adoptions Franchise Consultant Fraternal Freight Transportation Frozen Yogurt Fruit Fulfillment House Fund Raising Funeral Directors Funeral Homes/Cemeteries Furniture Furniture Dealers-Retail Furniture Manufacturers Furniture Renting Furniture/Custom Garage Doors/Openers Gardening Supplies Gas Company Gas Station Gift Baskets/Gift Shops Glass Golf Carts Golf Courses/Clubs/Driving Ranges Golf Equipment & Supplies Golf Tournament Gourmet Foods Government Granite Countertops Graphic Design/Arts Graphic Printing Grease Traps Green Business Grinding Grocers/Retail Gym Gymnastics Hair Care Products Hair Cutting & Styling Hair Pieces/Wigs Hair Removal Hair Salon Handyman Services Hauling - General Health & Fitness Retreat Health & Human Services Health & Wellness Center Health & Wellness Products Health Assessment Health Care Management - Elderly & Disabled Health Care Manager/Provider Health Care Products/Consultants Health Consultants/Research Health Food Store Health Insurance Hearing Aids Home Based Home Health Service/Care Home Heating Fuel/Oil Home Improvements Home Inspections Home Theater Systems Homeless Shelters Homes Rental/Sales Hospitals Hotel Developer Hotel/Motel Hotel/Motel - Superior Small Lodging Human Resources Hydroponics Ice Cream/Frozen Desserts Imaging Import/Export Individual Indoor Air Quality Service Industrial Maintenance Industrial Product Distributor Information Technology Insurance Insurance - Annuities Insurance - Auto Insurance - Commercial Insurance - Corporate Insurance - Flood Insurance - Health Insurance - Home Insurance - Life Insurance - Workers Comp Interior Decorators/Designers Internet Access Internet Classified Internet Consultants Internet Kiosk/Advertising Internet Marketing Internet Marketing/Web Development Internet Provider/Web Page Designer Internet Security Internet Site Inventory Services Investment Management Investments/Marketing Investors - International Invitations & Announcements IT Janitorial Service/Supplies Jewelers/Appraisers/Retail Kitchen & Kitchen Design Laboratory Testing Services Land Developers Landscape Contractors Laundry Law Enforcement Law Office Lawn Maintenance Leather/Vinyl Repair Legal Services Library Library Administration Lighting Fixtures/Retail/Wholesale/Flourescent Lightning Protection Limousine/Transportation Service Locksmiths Logistics Acquisition Support Low Income Housing Luxury Home Community Magazine/Broker Mail Services/Systems Management Consultants Management Recruiters Manufactured/Mobile Home Dealers Manufacturers Manufacturing Representative Mapping Maps/Globes/Lamination Marinas Marine Fuel Marketing Marketing Agency Marketing Research Marketing/Direct Mail Martial Arts Massage Therapy Mattresses Meat/Cheese Distributors Mechanical Contractor Media Media Consolidator Media Research Mediation/Dispute Resolution Medicaid Planning Consultant Medical Billing Medical Care Medical Equipment & Testing Medical Imaging/Service/Sales Medical Records Services Medical Research Medical Spa Medical Systems Medical Transcription Medicare Supplements Meeting Planner Meeting Space Memory Care Mental Health Center Merchant Services Message Services Metal Fabrication Military/Veterans Mirrors Mobile Home Appraiser Mobile Home Park Mobile/Cellular Phones Mold Inspection & Remediation Mortgage Brokers/Lenders/Leads Mortgages Motivational Speakers Motorcycle Rental Motorcycles/Scooters Moving Companies Mufflers Multimedia Museums Music Backgrounds Music Production Music Stores & Instruments Nail Salons Natural Gas Networking Groups News/Politics Newspapers Night Club/Lounge Not-for-Profit Organization Nurseries/Plants/Trees Nursing Homes Nursing Homes/ALF Nursing Service Nutrition Occupational Therapy Office Buildings/Leasing Office Furniture/Equipment & Service Office Rentals Office Services Office Systems/Supplies Online Media Ophthalmologists/Laser Surgery Ophthalmology/Optometry Optical Manufacturer Optical Network Equip. Mfgrs. Opticians Optometrists Oral Surgeon Orthodontist Orthopedics Out Placement/Human Resources Outdoor Living Packaging Equipment & Machinery Pain Management Paint/Retail & Wholesale Painting Contractor Paper - Shredded Parking Services Party Goods & Supplies Party Planner Patent Drawings Paving Contractors Pawn Shops Payroll Processing Personal Assistant Personal Coach Personal Defense Personal Loans Personal Trainer Pest Control Pet Grooming & Supplies Pet Services Pet Sitting Pharmaceutical Pharmaceutical Returns and Disposal Pharmacies Phone/Internet Service Photographers/Photography Photography/Advertising Physical Therapy Physicians Pianos/Retail Plants Plaques & Trophies Plastic Products Manufacturer Plastic Surgeons Plumbing Contractors Plumbing Fixture/Supplies/Wholesale/Retail Political Consultants Pool Maintenance & Service Pool Service Post Office Pregnancy Resource Center Pressure Washing Printer Printing Equipment/Supplies Printing/Promotional-Gifts Private Investigators Project Management Promotional Products Property Casualty Insurance Property Management Psychiatry Public Relations Publishers & Publications Pumps & Pumping Equipment Purchasing Agents Quartz Countertops Radio Stations/Programs Real Estate Appraisers/Inspections Real Estate Auctions Real Estate Broker Real Estate Commercial Real Estate Developers Real Estate Investment Real Estate Management Real Estate Rentals Real Estate Residential Real Estate Services Realtor Records/Retail/Service Records/Storage/Management Recreation - Indoors Recycling Referral Services Refinishing Rehabilitation Relocation Services Remodeling Services Rental - Short Term/Seasonal Rental Furniture Rental/Misc. Items Residential Detox Residential Rental Furniture Resorts Restaurant - Equipment Repair Restaurant Supplies Restaurants Retail Retail Development Retail Software Retirement Homes/ALF Retirement Living Reverse Mortgage Lending Road Construction Roof Contractors RV Dealership RV Parks RV Resorts Safes Sailboat Charters Sales Training/Seminars Sales Verification Sales/Leads Sales/Marketing Consultants Sanitation Consultants & Services Scholarships/Grants School Supplies/Apparel Schools - Charter Schools/Kindergarten Schools/Private Schools/Professional Schools/Special Education Schools/Technical Scooters - Wholesale Scrapbooking Screen Printing Scuba Diving Seafood/Retail/Wholesale Security Consultants Security Systems - Commercial Security Systems - Residential Security Systems/Services Senior Citizens' Service Senior Living SEO Service Clubs Service Stations Shipping Services Shipping/Packing/Binding Shoes/Retail Shopping Center Developer Shopping Center Leasing Shopping Centers/Malls Shutters Signs Sink Hole Remediation Skin Care Treatment Social Networking Social Services Software Software Development/Engineering Sound Systems Spa Special Events Specialty Stores Speech Pathology Sporting Clubs/Events Sporting Goods/Rentals Sports Bar Sports Memorabilia Sportswear Staff Augmentation Stock & Bond Brokers Storage Storm Protection Student Loan Consolidation Student Services/Internships Sunscreen Products Surf Shop Surgeons Surveyors/Engineers Swimming Pool Contractors/Dealers/Maint. & Serv. Tailors Tax Planning/Consultants Tax Preparation Taxi Services Technology Development Technology Solutions Telecommunications (Cable, Internet, Wireless) Telecommunications for the Hearing Impaired Telephone Equipment Television Productions Television Stations Tennis Club Theatres/Dinner Theatres Theme Park Thrift Shop Ticket Sales Tile Contractors Time Shares Tire Dealers/Service Title Companies Tourism Tours/Travel Towing Trade Show Display Training Support Training/Development/Services Training/Personal Development Transmissions Transportation Travel Agencies/Brokers Travel Services Tree Services Truck Rental/Leasing/Brokering Trust Service Uniforms/Retail/Rental Urgent Care Utilities/Public Vacation Clubs Vacation Incentives Vacation Rentals Vacation/Travel Resource Valet Service Vending Companies Venture Capital Veterinarians Video Conferencing Video Production Service Video Surveillance Vision Care Voice and Data Integration Wallpaper Waste Management Watches/Sales/Repair Water Coolers Water Management Water Purification Water Softening Water Sports Water Treatment Water/Bottled Web Development Web Site Design Web Site Design/Multi Media Wedding Ceremonies Wedding Photographer Wedding Planners Weight Management Welcome Service Wheelchair Services Wholesale Surveillance Equipment Wholesale/Distributors Wildlife Park Window Tinting Window Treatments Window/Sales Wine Bar Wine Consultant Wine Importer / Distributor Winery Wireless Communication Womens Apparel Wood working machines Workflow Workspaces Yacht Clubs Yachts Yellow Pages Yoga Youth Services Zoo Additional Directory Categories Select additional directory categories below by holding the "CTRL" key none Number of Employees Annual Membership Investment RGA Total Payment Type Credit Card Invoice/Pay by Check NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. 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Number of Part Time Employees Number of Rooms Number of Seats Number of Associates Number of Locations Millions in Assets Additional Categories Cost One-Time Application Fee Tax Full-Time Employees Part-Time Employees Hotel/Motel Rooms Restaurant Seats Additional Associates Additional Associates Cost Additional Locations Additional Locations Cost Assets Assets Cost Additional Categories Number Of Additional Categories Additional Categories Cost RGA + for Discover Level RGA + for Empower Level RGA + for Propel Level RGA + for Magnify Level RGA + for Amplify Level Additional Item 6 Cost Additional Item 7 Cost Additional Item 8 Cost Additional Item 9 Cost Additional Item 10 Cost Annual Dues (charged to card) Revenue Item Tax (charged to card) Fee (charged to card) RGA Type Temp Value For DropDown 1 Membership Type Additional Item 2 Additional Item 3 Additional Item 4 Additional Item 5 Additional Item 6 Additional Item 7 Additional Item 8 Additional Item 9 Additional Item 10 Credit Card Information Copy from Organization Information Credit Card Type MastercardVisaDiscoverAmex Credit Card Number Name on Card Security Code Valid Through 01 02 03 04 05 06 07 08 09 10 11 12 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 Address City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Zip Phone Credit Card Email Address By submitting this application you confirm that your organization aligns with the mission of AMPLIFY Clearwater which is to promote and meet the needs of businesses, tourism, and industry and to provide leadership for the advancement of economic vitality and equality for the community of the North Pinellas Region. 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