Membership Application

1

Business Info

Provide business ownership details.
2

Store Details

Provide store and mailing addresses.
3

Tax & Registration

Add EIN, SSN, and tax ID numbers.
4

Owners/Partners Info

List all owners and ownership percentages.
5

Representative

Choose a voting representative
6

Store Manager

Add store manager details.
7

References

Add two member references.
8

Signature

Digitally sign your application.
9

For Office Use Only

Internal section for office processing.
Business Information And Ownership Details
Store Address
Mailing Address
Contact Information
Previous Association Membership Details
Tax & Registration
Member Company Owners/Members/Partners/Stockholders Information
Note: If sole prop. or partnership need SS# for each Partner:
The Association may request written verification, in a form acceptable to the Association, regarding Member's proof of ownership of Member's business whether the Member's ownership is a Sole Proprietorship, Corporation, Limited Liability Company, Limited Partnership, General Partnership, or any other form of ownership.
Authorized Representative Information
Note: An ā€œAuthorized Representativeā€ of a Member must be a natural person who is an owner of the Member and who otherwise meets the Governing Documents. Information of Authorized Representative of Member (Person responsible for making all business decisions including VOTING)
Store Manager Information
This person will not be eligible to vote or sign any documents or make any changes

TWO REFERENCES / RECOMMENDATIONS

Note: NO SELF REFERENCES* (Two references from two different existing Association members who are not on this application)
First Reference
Second Reference
The undersigned authorized officer and authorized representative of Member hereby represents, warrants, and certifies that
(i) the information provided in this Membership Application is true, correct and complete in all respects,
(ii) Member accepts and agrees to be strictly bound by and to strictly comply with the Governing Documents and its directors and officers,
(iii) The undersigned individual listed as Member's Authorized Representative shall be solely and exclusively authorized to act on behalf of Member (until the designated authorized representative is properly changed in writing in accordance with the Association guidelines and requirements) with respect to all the Association matters, including, but not limited to, exercising the member's voting rights, and
(iv) the undersigned hereby accepts the designation of Authorized Representative and agrees to fully perform all obligations, duties, and requirements required of him/her by the Association in such capacity.
Signature of Designated Authorized Representative
Date of Signature
Printed Name of Designated Authorized Representative
Note: Acceptance of Annual Dues by the Association does not automatically imply acceptance of Membership Agreement or Membership Application. The collected fees/deposits will be returned if the Membership Application is not approved by the Board of Directors. Acceptance shall only occur upon written approval by the Board of Directors. Please sign this Membership Application and the attached Membership Agreement and return both with the documents listed on the checklist (the first page of this membership package).

FOR OFFICE USE ONLY

Received By
Verified By
Approved by
Membership Effective Approval Date (Effective Date of the Membership Agreement)
Membership Assignment and Payment Details