Application

To view this form, please enable JavaScript in your browser.

Organization Information (to be displayed online)
Main Contact
Additional Contacts

Contact 1

Contact 2

Contact 3

Contact 4

Contact 5

Contact 6

Contact 7

Contact 8

Contact 9

Contact 10

Billing Address (if different)
Mailing Address (if different)
Additional Information

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
  • Select additional directory categories below by holding the "CTRL" key
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

The contents of this box are for testing purposes. This box will be removed when the form goes live.
 
 
 
 
 
Credit Card Information

Name on Card
Security Code
Valid Through
Address
City
State
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.

Please click submit only one time.  The transaction may take several seconds.