Associate Member Application

Company Name(Required)

Company Website

Contact Name(Required)

Contact Email(Required)

Phone(Required)

Fax

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Type of Firm

Wholesale Distributor

Manufacturer

Manufacturer's Rep or Agent

Type of Product/Work

(i.e., plumbing service truck bodies, shelving & bin storage)

Additional names and Email Addresses:

(If you wish additional employees in your firm to receive electronic information please provide their names and email addresses)

Annual Dues: $300 (Jan. 1 through Dec. 31). If you want to join Greater Indianapolis in addition to Indiana PHCC, it is an additional $75. Just click on the "Add Greater Indianapolis radio button.

Indiana PHCC Member Dues

Price:

Dues includes access to PHCC local chapters. Some chapter meetings are not open to associate members.

Add Greater Indianapolis ($75)

Yes

GIPHCC has a separate associate member dues. To gain full access to the Greater Indianapolis Chapter, add this membership.

Total

Make Checks Payable to Indiana PHCC | 12175 Visionary Way, Suite 500 | Fishers, IN 46038.

Or Pay By Credit Card

Name on Credit Card

Credit Card Number

Security Code

Expiration Date

Zip Code Associated With Card

Associate Member Application

Associate Member Application

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