City:  _________________ State:  ___________ Zip: ___________

Phone: ____________________ Fax: ________________________

E-mail:  ____________________ Web Site: ____________________

Number of employees: ___________ Number of Trucks: ___________

    Yearly Dues:                  
    Towing $ 300.00            Total enclosed: ________________________
    Vendor $ 200.00

Signature:  ____________________ Title: __________ Date: _________