Name __________________________________________________________________ Birthdate ______ / ______ / _____
Job title _______________________________________________________________________________________________
City _______________________________________________ State/Province_______________________________________
Country ____________________________________________ Zip/Postal code ______________________________________
Business phone ______________________ Fax _______________________ Web address ___________________________
Email address (office) ________________________________ Email address (home) _________________________________
Membership fees are based on gross sales volume.
q Less than $1 million or newly formed company (less than 1 year) $375 $ _______
q $1 million to $5 million $560 $ _______
q $5 million to $15 million $930 $ _______
q $15 million to $50 million $1,380 $ _______
q More than $50 million $1,625 $ _______
Corporate membership includes one primary employee member (named above). Additional employee members*
may be added at an additional charge. Please use a separate form for each additional employee membership.
q *Additional corporate employee $65 $ _______
(must be employed by a member company)
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 firstname.lastname@example.org with your request.
Manufacturers Section Membership Application
Payment information (All fees listed are USD.) (Add an additional $25 for bank transfers.)
Total membership fees $ _______
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 ________________________________________________
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 email@example.com Websites NGWA.org and WellOwner.org
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