RURAL INDEPENDENT COMPETITIVE ALLIANCE
Associate Member Application
Dues Structure
$600/yearly (pro-rated quarterly)
Company Name
Address
City
State
Zip
Phone
Fax
Contact Name
Title
Phone Number
Email
Web Address
Method of Payment
Visa
MasterCard
AMEX
Discover
Card #
Exp. Date
Name on Card
Amount Paid:
Membership Fee
TOTAL