• Please provide the following contact information for this store:

  First name
  Last name
  Title
  Company
  Street address
  Address (cont.)
  City
  State
  Zip
  County
  Phone
  FAX
  E-mail
  Web address

• Date started in business

• Dealers

  Home Address
  City
  State
  Zip

• Associates:  Enter mailing address if different than entered above.

  Address
  City
  State
  Zip
  Phone

• Membership Category and Investment Schedule
  Choose one of the following options:
  

  	Equipment Dealer	$285.00
  	Multi-Location Equipment Dealer - Additional Branch	$150.00
  	Associate (manufacturer/supplier) - per person	$95.00

• Multi-Location
  If you selected the Multi-Location Membership Category from the above choices, each Branch will add $150 to your dues investment. Please complete one form for each location.
  
  
• Communications and Marketing Consent
  I represent that I am authorized to provide the foregoing consent and understand that by providing my mailing address, email address, telephone number(s) and fax number(s), I consent to receive communications sent by or on behalf of the Ohio-Michigan Equipment Dealers Association (OMEDA) and the North American Equipment Dealers Association (NAEDA), NAEDA Services, Equipment Dealers Foundation, and Iron Solutions via regular mail, email, telephone, and fax. I also understand that I may revoke this consent with respect to one or more of the entities listed above by notifying such entity in writing of such revocation at any time.

  I consent to receive Communications and Marketing items.

• Select any of the following items you carry at this store:

Agricultural Equipment

Lines Carried

Industrial Equipment

Lines Carried

Outdoor Power Equipment

Lines Carried

• Please provide the following owner/officer information for this store:

  Name of Owner/Officer	Title