Membership Application - Affiliate Form

Please take the time to fill out the information below to allow for a prompt processing of your application.


 

Membership Application - Affiliate Form
Please take the time to fill out the information below to allow for a prompt processing of your application.

Firm Name: *
St. Address: *
P.O.Box:
City: *
State: *
Zip Code: *
Phone:
Fax:
Email
Designated Representative *
Website
When did this firm begin conducting business? (month/year) *
When did this firm begin conducting business in the pet industry?(month/year) *
Applicant firm is a (check one)
Incorporated in what state, and when?(MM/DD/YY)
Name of all Partners.
Please describe.
Name of Officers:
President: *
Vice President: *
Secretary: *
Treasurer: *
Has Applicant any ownership connection or other affiliation (legal, business or familial) with any other firm in the pet industry? *
If Applicant answered yes provide explanation in the area below.
Is this other firm a member of WPA?
Has Applicant ever been a member of WPA? *
If Applicant answers yes, was it under the same name? If so, when and where.
If it was under another name, state name and years.
Do you issue a catalog? (if so please send in a copy)
Does Applicant make retail sales?
Check current industry memberships Applicant currently holds.
Briefly describe the general nature of your business. *
Brief description of products/services available to the pet industry. *
List three non-customer business references with address.
1. *
2. *
3. *
Please list the names of five active customers to be submitted with this application. *

Please attach a copy of your business license or other business document showing your company's legal business status. (i.e. a city business license.) *

Please attach a copy of your catalog or sales literature used in selling your products/services *

We agree to abide by the By-laws of WPA and with all regularly adopted amendments thereto. We also agree to conscientiously conduct our personal relationship with the trade and in all matters pertaining to business in conformity with recognized standards of business practice. We declare all information contained in this Application and questionnaire to be true and accurate. Further, we understand that acceptance of this Application and membership in the Association is subject to approval of its Board of Directors and that we will be notified of the Board's action.
By Applicant's acknowledgement below, Applicant consents to the dissemination of all information contained in or attached to this Application to members of the Association's Board of Directors in order that the Application may be processed notwithstanding the fact that some members of the Board may be competitors of the Applicant and Applicant herby releases the Association from any and all claims alleged to have occurred as a result of the release of information contained in this Application.
Permission is given to contact all references given in this Application.

Dues *

Clear Selection
Total Dues

Payment Information

Amount to Charge :
Payment Method:

  Yes, please notify me of upcoming WPA events.



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