West Branch Susquehanna Builders Association
1610 Whitman Street, Williamsport, PA 17701
COMPANY REPRESENTATIVE ________________________________ TITLE _____________________
COMPANY NAME __________________________________________ PHONE _____________________
MAILING ADDRESS _______________________________________ FAX _____________________
_______________________________________ E-MAIL _____________________
TYPE OF BUSINESS _________________________________ Website ___________________________
MEMBERSHIP CLASS: _____ BUILDER _____ ASSOCIATE YEARS IN BUSINESS ________
CUSTOMERS SERVED – 2 REQUIRED (NAME COMPLETE ADDRESS & PHONE):
MATERIALS SUPPLIERS (If applicable) – (COMPANY NAME, COMPLETE ADDRESS & PHONE):
My signature belows authorizes the above references to release information to the Executive Officer of West Branch Susquehanna Builders Association.
THE FOLLOWING DOCUMENTS ARE REQUIRED WITH THIS APPLICATION:
SIGNED CODE OF ETHICS FORM
FEDERAL ID NUMBER OR SOCIAL SECURITY NUMBER _____________________________
wORKERS COMPENSATION INSURANCE CERTIFICATE IF YOU HAVE EMPLOYEE(S).
lIABILITY INSURANCE CERTIFICATE, MINIMUM $100,000 INDIVIDUAL/$300,000 PROPERTY.
If you have requested your insurance carrier to mail certificates, please indicate.
I agree to abide by the Constitution, Bylaws and Code of Ethics of the West Branch Susquehanna Builders Association, the Pennsylvania Builders Association, and the National Association of Home Builders. A remittance of $ 395.00 representing my annual dues in the affiliated associations accompanies this application. NOTE: Included in the above dues amount is $15 for subscription to Builder Magazine. This amount cannot be deducted from the total. Dues payments to WBSBA are not deductible as charitable contributions for federal income tax purposes. However, dues payment may be deductible as ordinary and necessary business expense, subject to the exclusion for lobbying activity. Because a portion of your dues is used for lobbying by PBA and NAHB, $82.68 will not be eligible for the year 2010 for deduction as a business expense.
______________________________ __________________________________________
Date Applicant’s Signature
Sponsor: ____________________________________
PRINT FORM, COMPLETE AND MAIL OR FAX TO WBSBA.
Please charge my ___ Visa ___ MasterCard ___ Discover Amount $_____________
Name on Card _________________________________________________________________________
Card # _______________________________________________________________________________
Security Code on back (3 digits) ___________ Expiration Date _____________________
Signature _____________________________________________ Date _____________________