1.  How long has your company been in business?

2.  How long have you been employed by this company?

3.  Former Employers (list last three employers, starting with the first).

4.  Name three references (including  contact name, address and phone number of persons not related to you, whom you have known at least one year).

5.  Have you ever applied to any other association?

6.  Are you currently a member of any other associations?

I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that, if approved, falsified statements on this application shall be grounds for membership termination.

I authorize investigation of all statements contained herein and the references listed above
to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability from any damage that may result from furnishing same to you.

Print Name:________________________________________________________

Signature:_______________________________________

Date:_____________________