1. APPLICANT INFORMATION

Company Name     ____________________________________________________________

Principal Business   ____________________________________________________________
Mailing Address     ____________________________________________________________
Telephone Number ____________________________________________________________
Fax Number   _________________________________________________________________
Designated Representative  ______________________________________________________
Title or Position      ____________________________________________________________
E-mail address       ____________________________________________________________
Optional Information
Website address    ____________________________________________________________
Roster Information ____________________________________________________________
Spouse's Name     ____________________________________________________________
Home Address      ____________________________________________________________

2. INITIATION FEE AND DUES

Applicants agree that with 30 days of notification of the acceptance of its application, it will pay to the Association initiation fee, current dues in accordance with the following schedule:

NOTE: During the year of joining, annual dues will be pro-rated downward on a quarterly basis, to reflect payment for only that portion of the year still left. This would be based on the IPCMA fiscal year of October 1 through September 30.

The applicant understands and agrees that the Association my change the rate of such fees and dues from time to time, and may also levy assessments on members to meet the costs and programs of the Association, and the applicant agrees for the period of its membership to pay any such fees, dues or assessments at the rates approved by the Board of Directors.

3. GENERAL

The applicant agrees to furnish, if required, any additional information that may be requested by the Association to establish qualifications for membership.

The applicant also agrees to be governed by Association regulations in effect during the period of membership.

ACCEPTANCE

The above application is hereby accepted by the
INTERNATIONAL PACKAGED CONCRETE MANUFACTURERS ASSOCIATION.