All Fields Are Required (enter N/A where information is Not Available)
Company Name:	
Principal's Name:	
Address:		
City St Zip:	

Phone:		
Fax:		
E-Mail Address:	
Web Address:	

Brief description of the Products/Services your Firm provides:



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.
Partner dues are billed annually.  Please choose from the following Partner Levels:

	 Platinum Partner Member	$2550.00		 Bronze Partner Member	$800.00
	 Gold Partner Member	$1850.00		 Partner Member		$475.00
	 Silver Partner Member	$1250.00

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