Atlanta Chapter Membership Application

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The applicant, for affiliation in the IEC, shall be an independent legally licensed contractor. A breif statement of qualifications and experiences are listed below. The applicant states that he/she is in accordance with the stated principles of this Association, and agrees to abide by the Rules and Regulations of the Association as proclaimed in its Charter and Bylaws, and Authoritative Actions of its Board of Directors. He/she also agrees to pay this Association all dues, assessments and fees when due. 

Company Name:	
Address:		
City St Zip:	
Phone:		
Fax:		
E-Mail Address:	
Web Address:	
Years In Trade:	
Number of Employees: 


Principal's Name:	
Home Address:	
City St Zip:	
Home Phone:	


All Electrical License Numbers:

License Holder:	
Date Established:	




References
Electrical Contractor	Address			City ST Zip		Phone
			

Supply House		Address			City ST Zip		Phone
			

Customer			Address			City ST Zip		Phone
			

Membership shall be continuous.  In the event of termination or withdrawal, all dues shall be paid in full
as of that date.  This application is subject to the approval of the IEC Admissions Commitee.
An initiation fee of $100.00 must accompany this application.


Authorized by:   Date: 
IEC Sponsor:     Date: 





Credit Card Billing
We Accept: Mastercard, VISA,
and Discover


Initiation Fee: $100.00





Credit Card Number:		
Expiration Date:			
Name as it appears on the card:	
Credit Card Billing Address:	


If you are not comfortable with sending your credit card information over the internet or if you prefer
to pay by check you may fill in the information above, print it out, (if paying by check
 please enclose the check with the information)and....


		Mail to:	Independent Electrical Contractors
			4500 Winters Chapel Road
			Atlanta, GA 30360
 

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