| COMPANY INFORMATION |
| Company Name: |
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| Street address: |
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| Mailing address (if different from above): |
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| City: |
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| State/Province: |
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| Country: |
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| Zip/Postal code: |
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| Telephone: |
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| Facsimile: |
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| Company website: |
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| PRIMARY COMPANY CONTACT |
| Name: |
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| Title: |
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| Telephone (if different from above): |
ext.
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| Facsimile: |
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| E-Mail: |
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ALTERNATE CONTACT |
| Name: |
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| Title: |
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| Telephone (if different from above): |
ext.
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| Facsimile if different from above): |
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| E-Mail: |
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| MEMBERSHIP INFORMATION |
| Membership Categories: |
Raw Material Supplier - $3000/year
Raw Material Distributor - $800/year
Equipment Supplier - $800/year
Equipment Distributor - $800/year
Formulator / System Supplier - $800 / year
Consultant - $400/year
Contractor/Applicator/Owner - $250/year
Academic/Government/Student - $100/year
Independent Sales Representative - $250/year
Architect, Engineer, or Specifier- $125/year |
| Number of Employees: |
1-25
26-100
101-500
501-1000
Over 1000
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| General Interests (Select all that apply) |
Technical Information
Market Information
Equipment Information
Application Training
Health, Safety, & Environmental
Other
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| Market Interests (Select all that apply) |
Construction Products
Truck Bed Linings
Caulks and Sealants
Molding
Other
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| Please tell us about your company. List the type of service you provide or equipment you sell. |
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| Would you be interested in taking part in a PDA Committee? Please select the committee you're interested in: |
Technical (Safety/Health, Training/Certification)
Marketing (Marketing, Product Certification, Editorial)
Membership (Membership, International Chapters)
Other Interests?
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| Do you have questions or comments? |
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| If accepted as a member in the Polyurea Development Association, I agree to abide by the Bylaws of the Association, and pay all duly levied dues and assessments.
Yes |
| PAYMENT METHOD |
| Name on Card: |
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| Please charge my: |
VISA
Mastercard
American Express
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| Account Number: |
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| Expiration Date: |
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| Total: |
$
**Please note that your initial membership will include a $25 application fee. |
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