Company Name:	
Principal's Name:	
Address:		
City St Zip:	
Phone:		
Fax:		
E-Mail Address:	
Web Address:	

Georgia Licence Number:
Unrestricted:	
Restricted:	

Company Representative:	
Residence Address:		
City St Zip:		
Number of years in business: 
Number of Employees:	  

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 Board of Directors.

Membership Dues:  Both the State and National dues are based upon the number of field
employees including temporaries using the scales below.

One quarter of State dues and National dues must
accompany this application, and there after, will be invoiced quarterly.


Georgia Chapter Dues Scale
(includes Georgia dues and National dues)


		Number of Employees	Quarterly Dues
			0-5		$ 91.25
			6-10		$129.75
			11-20		$206.75
			21-60		$266.00
			61-100		$319.75
			101- 150	$396.75
			151- 200  	$499.50
			201+       	$630.50
			Each year National dues may increase based on the COLA


Authorized by:   Date: 
IEC Sponsor:     Date: 


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




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