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    Organization Name:

    Address:

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    Name of Chief Staff Executive:

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    Name of Second Contact:

    Title of Second Contact:

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    Please briefly outline the nature of your organization and the type of member and industry you represent:

    Number of Members:

    Amount of SBLC Dues based on the potential member’s total association budget:

    •If your association’s total budget is less than $500,000, your dues are $1,183.
    •If your association’s total budget is $500,000 to $1 million, your dues are $2,795.
    •If your association’s total budget is $1 million to $2 million, your dues are $3,467.
    •If your association’s total budget is $2 million to $3.5 million, your dues are $4,193.
    •If your association’s total budget is $3.5 million to $5 million, your dues are $4,945.
    •If your association’s total budget is $5 million or more, your dues are $5,590.

    $

    Mail completed dues check to:
    Small Business Legislative Council
    Attn: Sue Todd
    1905 South New Market Street, Suite 257
    Carmel, IN 46032

    MEMBERSHIP ELIGIBILITY:
    SBLC membership is open to associations whose members are predominantly small businesses or independent professionals.

    Please type your name for Electronic Signature: