Name __________________________________________________________________ Birthdate ______ / ______ / _____
Job title _______________________________________________________________________________________________
Employer ______________________________________________________________________________________________
Federal Employer Identification Number _____________________________________________________________________
Address ________________________________________________________________________________________________
City ____________________________________________ State/Province________________________________________
Country _________________________________________ Zip/Postal code _______________________________________
Business phone _______________________ Fax ________________________ Web address ________________________
Email address (office) _____________________________ Email address (home) ___________________________________
Membership options
Corporate membership — $375 $ ________
Corporate membership includes one primary employee member (named above) and two employees*. Each member receives all
benefits of membership, including publications. Additional employee members** may be added at an additional charge.
Please use a separate form for each additional employee membership.
*Please enter name and email address of the two additional corporate employees below:
Employee #1___________________________________Email address_________________________________________
Employee #2___________________________________Email address_________________________________________
**Additional corporate employee — $95 $ ________
(must be employed by a member company)
Professional Individual Membership — $375 $ ________
(Individual membership includes one individual.)
Please use a separate form for each additional employee membership.
NGWA occasionally makes members’ postal addresses available to vendor partners who supply products and services to the groundwater community. If you prefer not to be
included on these lists, please contact customer service at (800) 551-7379 or (614) 898-7791 outside the United States, or email customerservice@ngwa.org with your request.
Contractors Section Membership Application
Payment information (All fees listed are USD.) (Add an additional $25 for bank transfers.)
Total membership fees $ _________
Total optional services $ _________
TOTAL ENCLOSED $ _________
Membership may be paid by check, money order, VISA, MasterCard, Discover, or American Express (circle one).
Check/money order made payable to NGWA (enclosed) # _________________ Today’s date ________________________
Credit card # _________________________________________ Printed name _____________________________________
Expiration date ______________________________ CVC ________________________________________________
Signature _______________________________________________________________________________________________
Brokerage and customs charges may be applied. Dues may be deductible as an ordinary and necessary business expense to the extent not allocated to lobbying
expenditure. NGWA estimates that the nondeductible portion of dues is 10%.
Address 601 Dempsey Road, Westerville, Ohio 43081-8978 U.S.A.
Phone (800) 551-7379 • (614) 898-7791 Fax (614) 898-7786
Email ngwa@ngwa.org Websites NGWA.org and WellOwner.org
C-APP-2021-01
The Groundwater
Association
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