Application

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Company Information (to be displayed online)

Company Name

Address 1

Address 2

City

State

Zip

Phone

Fax

Website

Main Contact

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First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

Additional Information

Please submit a 40-word description of your company, including the products or services to be offered to the community banks in the state of Virginia

List the Virginia community banks with which you presently conduct buiness. Alternatively, if your membership is to establish business with the Virginia community banks, please list the community banks in another state to which you offer your services

Membership Investment

Membership Type

Primary Directory Category

Additional Directory Categories

Select additional directory categories below by holding the "CTRL" key
Secondary categories may be subject to additional fees

Total

NOTE: Dues must be paid with an initial application prior to membership consideration by the VACB Board of Directors. Once an application is approved, dues are not refundable. If the application is not approved, dues paid will be refunded.

Credit Card Information

Copy from Organization Information

Credit Card Type MastercardVisaDiscover

Credit Card Number

Name on Card
Security Code
Valid Through
Address
City
State
Zip
Phone
Credit Card Email Address

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