Business Name:     

  My business should be listed under these categories on the Alliance website:  (e.g. Accounting, Restaurant, etc)

   and 

  Address:                

  City:                     

  State:                  

  Zip:                                               

  Phone:                                    Year Started Business:        

  Fax:                                        Number of Employees:       

  Cell Phone:           

  Website:              

  E-mail:                  

  Name:                  

  Title:                   

  Comments:           

  Is your business independent of any third party control or direction?  Yes   No

  (Note:  A business is not considered independent if it is a franchise or participates in a branded purchasing cooperative)

  Would you be willing to volunteer for the organization?    (Check the box for "Yes")

  Would you be willing to participate on a committee?        (Check the box for "Yes")

  I can donate services or goods of:                                   

  How did you hear about the Will Buy Locally Alliance?       

  What keywords did you use in your search?                      

Please Note:  All membership applications are subject to approval in accordance with the guidelines of the Alliance.