Company
& Contact Information
Company:
Address:
City:
State
Zip/Postal Code:
Country:
Telephone:
Fax:
Primary Contact:
Title:
E-Mail Address:
Web Site URL:
Referred by:
Detailed Company Description:
Add'l Contact #1 to Receive Mailings :
Add'l Contact #2 to Receive Mailings:
Membership
Category
Principal Member
- $2,200 (U.S. Dollars)
Personalizer Member
- $2,200 (U.S. Dollars)
Associate Member
- $3,000 (U.S. Dollars)
Manufacturer Representative
/ Sales Agent Member - $1,650 (U.S. Dollars)
Consulting Member
- $1,100 (U.S. Dollars)
Branch Member
- $1,000 (U.S. Dollars)
Issuer Member - $3,000 (U.S. Dollars)
Affiliate Member - $1,500 (U.S. Dollars)
Corporate Member (up to 4 locations) - $5,000 (U.S. Dollars)
Corporate Member (5-10 locations) - $10,000 (U.S. Dollars)
Payment
Method
Check to be Mailed
Wire Transfer information requested
Credit Card
Credit Card #:
Exp. Date (e.g. 03/99):
Name on Card:
NOTE: This on-line submission does not
formally qualify you for membership. Membership is subject to approval
by the ICMA membership committee. Dues must be received before application
processing is complete.NOTE: Payments to ICMA are not tax deductible as charitable contributions for US Federal income tax purposes. However, they may be deductible under other provisions of the Internal Revenue Code.