member application

Select the territory and section for your company/organization.  For more information on territories, please view our area maps.
Territory
Category
Please enter company/organization information.
Company
Contact Name
Address
Alternate Address (P.O Box, etc.)
City
State
Zip
Phone
Alternate Phone
Fax
Email
Website (please include http://)
Do you wish to receive leads from website inquiries? Yes No
If yes, please tell us the e-mail address you would like the leads sent to...
Membership Class - Once approved, you will receive an invoice within 30 days.
Membership Class
Please upload your company/organization logo as a jpeg file of at least 250 pixels wide and no more than 400 pixels high. Click the Browse button below to locate the file on your hard-drive.
Logo

Map to your location.  Click here for more information. (optional)
Map Link
Please tell us who referred you to NC Coast Host
Referred by
Two to three sentence description to appear on your listing. (optional)
Please select a username and password.  You may either enter your own, or use the random username and password.  You can create another randomly generated username and password by pressing the "Generate Random Username/Password" button.  Remember your username and password.  You will need this to edit your info.
Username
Password
NOTE: When logging in, username/password are case sensitive.
You're almost done.  Please press the "Submit Application" button.
NOTE: Your information will not appear online until membership fees have be received.