membership application form - National Rural Electric Cooperative ...

Associate Membership ApplicationCompany Name (as you would like it listed in the annual Associate Membership directory and on the NRECA website)Product or Service Description (10-15 words):Primary NRECA Contact Name & Title (the person that your company prefers electric cooperatives contact):NameMailing AddressCity/State/ZipTelephone Mobile FaxE-MailWebsiteSecondary NRECA Contact Name & Title (NRECA will contact this person regarding marketing/advertising opportunities):Name Telephone E-MailAre you currently working with cooperatives? Yes NoIf yes, provide a co-op contact to nominate your company for membership. If no, skip to Level of Membership section.Cooperative NameCity/StateTelephoneCooperative Contact Name & TitleSelect Your Level of Membership: Platinum ($14,000) Gold ($7,500) Silver ($1,500)Provide an Invoice Contact (all NRECA invoices will be sent to this person):ContactTitleMailing AddressCity/State/ZipTelephoneE-MailCurrent tax status: Taxable, Incorporated in the state of Tax-ExemptPlease note: Associate Membership in NRECA does not signify an endorsement of products or services. Associate Members shall not claim or imply thatAssociate Membership signifies an endorsement by NRECA of products or services.TERMS OF AGREEMENTI understand that in order to be eligible for Associate Membership in NRECA, my company’s objectives will contribute to the objectives of the Association.The Chief Executive Officer of NRECA may request that any specific associate membership be cancelled if he so deems that the specific company no longercontributes to the objectives of the Association. If my company becomes ineligible for Associate Membership, any unused Associate Membership benefitsremain the sole property of NRECA.Authorized SignatureDateSUBMITTING YOUR APPLICATIONSTEP 1: Submit Your Application - online at www.nreca.coop/associatemembership or fax to 303.644.4857 or email to nancy.mcmahen@nreca.coopSTEP 2: Select a Method of PaymentPay by Check - please mail check and application to:C/O Nancy McMahenNRECA Associate Membership2149 South County Road 137Bennett, CO 80102STEP 3: Select up to four (4) business categories on the reverse side of this applicationNeed Help? Contact Nancy McMahen via phone, 800-230-2601 or via email at nancy.mcmahen@nreca.coop.Pay by Credit Card: Call 800-230-2601(be sure to fax/email your application, see Step 1 above.)Invoice Me(Invoice will be sent directly to Invoice Contact listed above)