Join DEBA

DEBA Membership Application

Business Information
Business Name*
Business Start Date*
Date Format: MM slash DD slash YYYY
Type of Business*
- Non-Profit and Government
- Restaurant
- Service
- Shopping
Business Phone*
Business Fax
Business Email*
Business Location*
Street Address Address Line 2 City State ZIP Code
Mailing Address [if different]
Same as Location Address

Street Address Address Line 2 City State ZIP Code
Contacts
Primary Contact Email*
Primary Contact Name*
First Last
Primary Contact Title*
Primary Contact Cell #*
For Internal Use Only
Primary Contact Birth Day*
For Internal Use Only
MM
DD
YYYY
Secondary Contact
Secondary Contact Name
First Last
Secondary Contact Title
Secondary Contact Cell #
For Internal Use Only
Secondary Contact Birth Day
For Internal Use Only
MM
DD
YYYY
Social Media Accounts
Website
Facebook
Google+
Instagram
LinkedIn
Twitter
Youtube
Other Social Media
Pinterest, Yelp, Yext
Website Name Website Address
Membership and Payment
Select Membership Level*
- DEBA Membership ($300 yearly prorated)
- DEBA Membership ($75 quarterly)
- DEBA Membership ($25 monthly)
- Associate Membership ($100 yearly)
Preferred Payment Method*
- Check
- Credit Card
Payment Due
$0.00
Billing Address [if different]
Same as Location Address

Street Address Address Line 2 City State ZIP Code
Consent*
Check: Make payable to DEBA.
- Please return to DEBA or drop off to Michelle Schaefer, Treasurer.
- 19 East Hurd, Edmond, OK 73034.

Credit Card: Call Treasurer Michelle Schaefer at 340-4998 to arrange payment.

Monthly or Quarterly Bank Draft: Must bank at Citizens and complete forms.

For questions regarding membership payment please call Michelle Schaefer at (405) 340-4998.
I agree to contact DEBA about payment.
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Website Name	Website Address

Join DEBA

DEBA Membership Application

Business Information

Contacts

Secondary Contact

Social Media Accounts

Membership and Payment