Young Professionals of the Coulee Region Application

First Name *

Last Name *

Job Title

Employer

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Email Address *

Phone Number *

Best phone number to reach you at.

Cell

(optional, for text reminders)

Date of Birth *

Format: M/d/yyyy

Required to confirm the age restriction of 21-40 year old individuals.

Applying as a

La Crosse Area Chamber Member ($50/year) La Crescent Chamber Member ($70/year) Non-Member ($110/year)

Please tell us why you want to join the Young Professionals of the Coulee Region *

What is the best way to contact you? This will be used to alert you to upcoming YP events and other important information. *

Call (Cell Phone) Text (Cell Phone) Email Call (Work Phone)

Payment Method *

Please specify how you wish to be billed.

Please select which one applies:

I have lived here all my life. I grew up here and moved back. I relocated here and found a job. I was hired and then relocated here.

Please specify who is funding this membership

Employer Personally