Firm Name:

Member's Name:

Address:

City:

State:

Zip:
    

Phone:

Fax:

License #

E-mail:

Web Address:

To compute your annual joint membership dues fill in lines A, B & C below.

A. State Annual Dues

1. Active member dues $125.00 per year...$
                                         or
2. Allied member dues $125.00 per year...$

B. NPCA Annual Dues
Choose one from box below and enter here...$

Annual Sales Volume	Annual Dues
$0 - 200,000	$110.00
$200,001 - 500,000	$180.00
$500,001 - 1,000,000	$470.00
$1,000,001 - 2,500,000	$715.00
$2,500,001 - 5,000,000	$1,210.00
$5,000,001 - 10,000,000	$3,025.00
$10,000,001 - 15,000,000	$4,675.00
$15,000,001 - 25,000,000	$6,325.00
$25,000,001 - 50,000,000	$11,750.00
$50 million - 100 million	$23,100.00
Over 100 million	$35,000.00

C. Total annual joint membership dues.......$

I understand that by initialing here, I am agreeing to remit by mail the full amount of my membership dues to the Arkansas Pest Management Association. Initial here: