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Company Name:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone:
Fax:

Address:
City:
State/Province:
Zip/Postal Code:
Country:

Company E-Mail:
Website URL:
Year Company Founded:

Type of Ownership:
 Individual Ownership
 Corporation
 Partnership

Territory Covered:
 Alabama
 Alaska
 Arizona
 Arkansas
 California
 Colorado
 Connecticut
 Delaware
 District of Columbia
 Florida
 Georgia
 Hawaii
 Idaho
 Illinois
 Indiana
 Iowa
 Kansas
 Kentucky
 Louisiana
 Maine
 Maryland
 Massachusetts
 Michigan
 Minnesota
 Mississippi
 Missouri
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 Nebraska
 Nevada
 New Hampshire
 New Jersey
 New Mexico
 New York
 North Carolina
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 Ohio
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 Oregon
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 Tennessee
 Texas
 Utah
 Vermont
 Virginia
 Washington
 West Virginia
 Wisconsin
 Wyoming
 Alberta
 British Columbia
 Manitoba
 New Brunswick
 Newfoundland and Labrador
 Northwest Territories
 Nova Scotia
 Nunavut
 Ontario
 Prince Edward Island
 Quebec
 Saskatchewan
 Yukon

Equipment Handled:
 Farm
 Garden
 Power
 Light Industrial

Service Category:
 Wholesalers
 Manufacturers Rep
 Retail Sales
 Warehousing
 Assembly
 Transportation of Equipment
 Light Manufacturing
 Heavy Manufacturing
 Service - In House
 Service - In Field
 Exporter
 Trade Shows
 Other:

Your Company's Prime Contact for Association:
Name:
Email:

Who Suggested Membership? (Not required for membership)
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Company:

 Marketing Associate Membership - Wholesaler Distributor
 Marketing Associate Membership - Independent Representative