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Nature of Membership : ______ Dealer ________ Vendor
_______ Service Providers -
(Check One)
Name
of Business :
___________________________________________________________________________________________
Address
:
_____________________________________________________________________________________________________
Contact
Name : ________________________________________ Email:
_______________________________________________
Tel:
_____________________________Fax : _____________________ Email:
_____________________________________________
Referred
by :
__________________________________________________________________________________________________
Change
of Address :
___________________________________________________________________________
(if applicable)
Tel:
_____________________________Fax : _____________________ Email:
____________________________________________
Signature:_________________________________________________________________________________________
(Print
Name):______________________________________________________________________________________
Approved
By : _____________________________________________ Dated : ______________________________
(Print
the Name) :
_________________________________________________________________________________
Membership
# : _________________________________________________ Dated :
_________________________
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