NGWA
SM
Manufacturers Division Membership Application
The Groundwater
Association
Name ___________________________________________________________________ Birthdate _______ / _______ / ______
Employer _______________________________________________________________________________________________
Address_________________________________________________________________________________________________
City ________________________________________________ State/Province_______________________________________
Country_____________________________________________ Zip/Postal code_______________________________________
Business phone _______________________ Fax________________________ Web address____________________________
Email address (office) _________________________________ Email address (home)__________________________________
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 (614 898.7791) or email customerservice@ngwa.org with your request.
Membership options
Membership fees are based on gross sales volume. (Please add $15 to rates for all non-U.S.A., Canada, or Mexico members.)
q
q
q
q
q
Less than $1 million or newly formed company (less than 1 year)
$1 million to $5 million
$5 million to $15 million
$15 million to $50 million
More than $50 million
$360 $535 $895 $1,325
$1,560 $________
$________
$________
$________
$________
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
(must be employed by a member company)
$60
$________
Optional member services
q Student sponsorship ($25 U.S.A./Canada/Mexico, $40 international) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $________
q Contribution to the National Ground Water Research and Educational Foundation (NGWREF) . . . . . . . . . . . . . . . . . $________
The National Ground Water Research and Educational Foundation, a 501(c)(3) public foundation, is focused on conducting educational research and other
charitable activities related to a broader public understanding of groundwater. Contributions are tax deductible to the fullest extent of the law.
Payment information (All fees listed are USD.) (Add an additional $25 for bank transfers.)
Total membership fees
$________
Total optional services
$________
TOTAL ENCLOSED$________
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 _______________________________Signature __________________________________________________
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 16%.
NGWA
SM
The Groundwater
Association
Address 601 Dempsey Road, Westerville, Ohio 43081-8978 U.S.A.
Phone 800 551.7379 • 614 898.7791 Fax 614 898.7786
Email ngwa@ngwa.org Websites NGWA.org and WellOwner.org
M-APP-01-11-2016