Affiliate Membership Application
Affiliate Membership Application American Traffic Safety Services Association Thank you for your interest in becoming an ATSSA member. Please read and fill out the sections below.
Step 1. Review the Affiliate Membership eligibility qualifications. Affiliate Member Qualifications: To qualify, the firm’s primary business: must be a provider of roadway safety services and/or devices, and the firm must not qualify for any other membership category. Affiliate Membership Annual Dues* Annual Revenue Under $1 Million …………………………. $1 Million to $1.9 Million ………………... $2 Million to $2.9 Million ………………... $3 Million to $3.9 Million ………………... $4 Million to $4.9 Million ………………... $5 Million to $5.9 Million ………………...
Amount $855.00 $1,245.00 $1,635.00 $2,025.00 $2,415.00 $2,805.00
Annual Revenue $6 Million to $6.9 Million ……………... $7 Million to $7.9 Million ……………... $8 Million to $8.9 Million ……………... $9 Million to $9.9 Million ……………... Above $9 Million -- Call for dues quote.
Amount $3,090.00 $3,585.00 $3,875.00 $4,005.00
* Dues for Affiliate Members are based on annual revenues from the roadway safety industry. Dues payments may be deductible as a business expense; however, dues are not deductible as charitable expenses for federal income tax purposes.
Chapter Selections I would like to receive information for the following Chapters (may select more than one): Arizona Arkansas California Carolinas (NC, SC) Chesapeake (DC, DE, MD) Florida Georgia Heart of America (KS, MO) Illinois
Indiana Iowa Kentucky Michigan Nevada New England (CT, MA, ME, NH, RI, VT) New Mexico Northland (MN, ND, SD) Northwest (ID, OR, WA)
Ohio Pennsylvania Rocky Mountain (CO, WY) Texas Virginia Wisconsin
I am interested in information on establishing an ATSSA Chapter in my state/region.
Step 2. Complete the membership application below (print or type). Contact Name: Pfx
First Name
M.I.
Last Name
Title Company Name Mailing Address City
State/Province
Zip
Country Phone
Fax
Email
Toll Free Website
Shipping Address if above is a PO Box Please fill out the parent company information if applicable: Parent Company Name Mailing Address City Country
State/Province
Zip
Please give a brief description (55 words or less) of the primary business functions of your company, the products, or services offered. This will be used in the ATSSA Membership Directory.
The undersigned hereby applies for membership and certifies that they meet all requirements for membership in the class requested. The applicant will be informed in writing when the application is approved. Acceptance of dues does not constitute approval of membership application. I hereby give expressed consent to receive ATSSA communications in accordance with the Federal Communications Commission (FCC) ruling and the Canada Anti-Spam Legislation (CASL). With the request and approval of your membership, you are agreeing to abide by the Association’s Code of Ethics, which you will receive in your new member welcome kit. This Code of Ethics establishes the principles and standards of conduct as a member of ATSSA. Name (Print)
Title
Signature
Date
Payment: Your first year’s dues must accompany this application. Make check payable to ATSSA. Membership Dues amount
$
Dues, contributions or gifts to ATSSA are not tax deductible as charitable contributions for income tax purposes. ATSSA estimates that the nondeductible portion of your dues allocable to lobbying is 12%.
RSAF Contribution $ (Roadway Safety Advancement Fund) Additional voluntary contribution to assist in ATSSA’s efforts to influence the transportation funding.
My check for
$
is enclosed Check #
Charge my card
$ VISA
MC
AMEX
Account No.: Exp. Date: Cardholder:
The Foundation Contribution
$
A suggested contribution of 10% of your dues may be deductible as a charitable contribution.
Total Remittance
Authorized Signature:
$ 0.00
Step 3. Mail, email or fax application and dues payment to: American Traffic Safety Services Association Attn: Member Services 15 Riverside Parkway, Suite 100, Fredericksburg, VA 22406-1022 540-368-1701 Fax 540-368-1717 [email protected]
www.atssa.com
06/14
Step 1. Review the Affiliate Membership eligibility qualifications. Affiliate Member Qualifications: To qualify, the firm’s primary business: must be a provider of roadway safety services and/or devices, and the firm must not qualify for any other membership category. Affiliate Membership Annual Dues* Annual Revenue Under $1 Million …………………………. $1 Million to $1.9 Million ………………... $2 Million to $2.9 Million ………………... $3 Million to $3.9 Million ………………... $4 Million to $4.9 Million ………………... $5 Million to $5.9 Million ………………...
Amount $855.00 $1,245.00 $1,635.00 $2,025.00 $2,415.00 $2,805.00
Annual Revenue $6 Million to $6.9 Million ……………... $7 Million to $7.9 Million ……………... $8 Million to $8.9 Million ……………... $9 Million to $9.9 Million ……………... Above $9 Million -- Call for dues quote.
Amount $3,090.00 $3,585.00 $3,875.00 $4,005.00
* Dues for Affiliate Members are based on annual revenues from the roadway safety industry. Dues payments may be deductible as a business expense; however, dues are not deductible as charitable expenses for federal income tax purposes.
Chapter Selections I would like to receive information for the following Chapters (may select more than one): Arizona Arkansas California Carolinas (NC, SC) Chesapeake (DC, DE, MD) Florida Georgia Heart of America (KS, MO) Illinois
Indiana Iowa Kentucky Michigan Nevada New England (CT, MA, ME, NH, RI, VT) New Mexico Northland (MN, ND, SD) Northwest (ID, OR, WA)
Ohio Pennsylvania Rocky Mountain (CO, WY) Texas Virginia Wisconsin
I am interested in information on establishing an ATSSA Chapter in my state/region.
Step 2. Complete the membership application below (print or type). Contact Name: Pfx
First Name
M.I.
Last Name
Title Company Name Mailing Address City
State/Province
Zip
Country Phone
Fax
Toll Free Website
Shipping Address if above is a PO Box Please fill out the parent company information if applicable: Parent Company Name Mailing Address City Country
State/Province
Zip
Please give a brief description (55 words or less) of the primary business functions of your company, the products, or services offered. This will be used in the ATSSA Membership Directory.
The undersigned hereby applies for membership and certifies that they meet all requirements for membership in the class requested. The applicant will be informed in writing when the application is approved. Acceptance of dues does not constitute approval of membership application. I hereby give expressed consent to receive ATSSA communications in accordance with the Federal Communications Commission (FCC) ruling and the Canada Anti-Spam Legislation (CASL). With the request and approval of your membership, you are agreeing to abide by the Association’s Code of Ethics, which you will receive in your new member welcome kit. This Code of Ethics establishes the principles and standards of conduct as a member of ATSSA. Name (Print)
Title
Signature
Date
Payment: Your first year’s dues must accompany this application. Make check payable to ATSSA. Membership Dues amount
$
Dues, contributions or gifts to ATSSA are not tax deductible as charitable contributions for income tax purposes. ATSSA estimates that the nondeductible portion of your dues allocable to lobbying is 12%.
RSAF Contribution $ (Roadway Safety Advancement Fund) Additional voluntary contribution to assist in ATSSA’s efforts to influence the transportation funding.
My check for
$
is enclosed Check #
Charge my card
$ VISA
MC
AMEX
Account No.: Exp. Date: Cardholder:
The Foundation Contribution
$
A suggested contribution of 10% of your dues may be deductible as a charitable contribution.
Total Remittance
Authorized Signature:
$ 0.00
Step 3. Mail, email or fax application and dues payment to: American Traffic Safety Services Association Attn: Member Services 15 Riverside Parkway, Suite 100, Fredericksburg, VA 22406-1022 540-368-1701 Fax 540-368-1717 [email protected]
www.atssa.com
06/14
