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SPONSORSHIP
 

APPLICATION FOR ASSOCIATE MEMBERSHIP
First Name: Last Name: Date:  
Owner or Operators Name:
 2/9/2010
Title:
Sponsored by:
  First Name: Last Name:
Second Contact Name:
             
Second Contact Title:
Doing Business As (name of your establishment)
Corporate Name (legal entity)
Location (address)
City
 State Zip
Mailing Address (if different)
City
 State Zip
County Business Phone Fax
WEB Site Address Email
Do you own additional locations?   Please check one
Yes
Franchise
No   Chain
If Yes, how many?   Independent
Please check the boxes for the endorsed services for which you would like information sent?(some conditions may apply)
Liberty Northwest-Workers Compensation Insurance Paychex - Payroll Processing and Tax Preparations
Liberty Northwest - Property & Liability Insurance Standard Biodiesel - Waste Vegetable Oil Recycling
ORA Health Insurance Program - Garth T. Rouse & Associates Careington - Discount Health Services
Micros - Point of Sale Systems AFLAC - Supplemental Health Insurance
Take Charge - Credit Card Processing Creative Center - Graphic Design and Marketing
BMI - Music Licensing  
Associate/Purveyor Membership Dues            
Purveyor dues are based on the number of employees for ALL Oregon units.
Please check the category which applies to your operation.		  
Number of Employees in Oregon Annual Dues    
1 to 24 $280    
25 or more $475    
Industry Affiliate (Government, Regulatory) $500    

 

 

 
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