Online Membership Application

Company Name

Address

City State Zip

Email Website

Phone Fax

No. of Years in Business

Main Contact (Designated Voting Representative)

Alternative Contact

CHECK ONE:

Distributor     Supplier     Importer     Mfg Rep     Service Provider

Number of years in business 

Territory covered 

Annual Dues: $350

SPONSOR REQUIREMENTS

One Distributor Member & One Supplier Member

1.

2.

Signature   Date