Business Application Form

Fields marked with an asterisk ( *) are required.

Please select a membership term and fill in the information below:

Membership Term:

Please select a membership.

Number of Employees:

Please select the number of employees.

# of Employees = FTE (2 PT at 20 hrs. = 1 FT)

Amount:

$ *

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Please fill out the following as you would like it to appear in your Online Profile on the Dane Buy Local website:

Business / Organization Name:	* Please enter a business name.
Contact First Name:	* Please enter your first name
Last Name:	* Please enter a last name.
Business Address:	* Please enter address.
City:	* Please enter a city.
State:	* Please select a state.
ZIP Code:	* Please enter a valid ZIP code.
Phone Number:	* (xxx-xxx-xxxx) Please enter a valid telephone number.
Email Address:	* Please enter a valid email address.
Website:	Invalid Input
Years In Business:	* Please enter the number of years in business.

Invoice Information:

Profile and Billing is the same Please select billing information.
If different, please provide your billing information:
Contact First Name:	* Please enter a first name.
Last Name:	* Please enter a last name.
Address:	* Please enter address.
City:	* Please enter a city.
State:	* Please select a state.
ZIP Code:	* Please enter a valid ZIP code.
Phone Number:	* (xxx-xxx-xxxx) Please enter a valid telephone number.
Email Address:	* Please enter a valid email address.

Member Referral (internal use):	Invalid Input
Number of Employees (internal use):	* Please enter the number of employess.

Does your business meet our member criteria? (Check the appropriate box and further explain below):

YesNo Please select an Yes or No	Is your business or nonprofit located in Dane County or counties contiguous to Dane County (Columbia, Dodge, Green, Iowa, Jefferson, Rock, and Sauk)? *

YesNo Invalid Input	Is your business or organization registered in Wisconsin? *

YesNo Please select an Yes or No	Do more than 50% of owners, Board members, or officers live in Dane County or contiguous counties? *

YesNo Please select a Yes or No	Is your business or organization a part of a franchise? * If Yes, where is the home office located?

YesNo Please select an Yes or No	Are the corporate headquarters of your business or organization located within Dane County or contiguous counties? *

YesNo Please select an Yes or No	Does your business or organization independently control purchasing decisions allowing you to buy goods, products or services from vendors of your choosing? *

YesNo Please select an Yes or No	Can your business or organization make independent decisions regarding the name and look of the business, including marketing, advertising, logo design, and branding decisions? *

YesNo Please select an Yes or No	Does your business or organization make independent decisions regarding business procedures, practices and policies? *

I want to receive the bi-weekly Dane Buy Local Buzz e-Newsletter * Invalid Input
I want to receive the monthly Dane Buy Local Deals e-Newsletter Invalid Input
Do You Accept the Dane Buy Local Gift Card? * More Info >>
Yes No Please select a option.
Category - Please select one of the following categories *
Arts & Entertainment Beauty & Fashion Boat, Bike & Auto Business Services Energy & Environment Finance, Insurance & Real Estate Food & Beverage Gifts & Shopping Health & Fitness Home & Garden Legal & Accounting Marketing & Media Partner Restaurants & Hospitality Citizen Supporter Please select a category.
Would you be interested in hosting a future Membership Breakfast or Evening Social? * More Info >>
Yes No Please select a hosting option.
Regardless of the foregoing criteria, Dane Buy Local reserves the right to decline membership to any entity that, in the sole discretion of Dane Buy Local, is not in accordance with the spirit or mission of Dane Buy Local.
Date:	* Please select a date.
By joining Dane Buy Local I pledge to consider local buying options when making purchasing decisions Invalid Input
Please make check payable to Dane Buy Local and remit to: Dane Buy Local 6300 Enterprise Lane Madison, WI 53719 Please direct all questions to Ms. Lark Paulson, Director of Membership Services, at c: 608-250-0966 / o: 608-729-7345 or lark@danebuylocal.com.

Please Fill in the Following to Complete Your Online Profile Information (not required at this time, but recommended):

5-10 Keywords (these are the same type of keywords entered into a Google search)
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Product / Service
What products and services do you offer, what's unique about your business (120 word limit)?
Invalid Input You have characters left.
Buying Local
Why is buying locally important to you? How do you show commitment to local vendors or products in your business (120 word limit)?
Invalid Input You have characters left.
History
When did your business start, by whom, how and why? (120 word limit)?
Invalid Input You have characters left.

Digital Photo An ideal photo is one representing your friendly faces and/or the type of business you do
Check the following boxes to confirm that your photo meets our requirements:
Photo is a jpg format Dimensions of photo are 372 pixels wide by 282 pixels tall Invalid Input
Please upload the image again
Please enter the security code:	If you can't read the characters in the picture above, click here Please enter a valid security code.