| Nature of Membership : Dealer__________ Vendor __________ Service
Provider ________ (Check One) |
| Name or brand of business:
_____________________________________________________________ |
| Address :
___________________________________________________________________________ |
| Contact Name:____________________________ Email:
_____________________________________ |
| Tel:_____________________________________
Fax:_______________________________________ |
| Referred By
:_________________________________________________________________________ |
| Change of Address
_________________________________________________________ (If Applicable) |
| Tel :_________________ Fax : __________________ Email :
_________________________________ |
| Signature : _________________________________ (Print Name) :
_____________________________ |
| |
| Membership ID # :____________________________ Dated :
__________________________________ |
| Approved By : _______________________________ (Print Name) :
_____________________________ |
| Membership Status : Active________________ Suspended : ______________
Cancelled : ____________ |
| Comments if any :
_____________________________________________________________________ |
| Comments if any :
_____________________________________________________________________ |
