Company Name:

Company Type:

Names of all Owners, Partners, Officers:

Contact Person authorized to receive mail and make decisions on behalf of the company:

Company mailing address (include zip):

Geographic Location if different from mailing address:

UPS Address if different from mailing or geographic address:

Phone:

Fax:

Email:

Website:

Company logo to be used in the buyer's guide

Business Reference (include individual, company, address & phone number):

Product or Service (Describe as we should list in the newsletter and Buyer’s Guide):

Associate Membership Application