Licensee Name:

Company Name:

Physical Address:

City, State, Zip:

Mailing Address:(If different)

City, State, Zip:

Your email:

Phone Number:

Fax Number:

Your Website:

License Number:

Date Established:

State Registered Employees (Licensees and Technicians):

Membership Category:
Voting Membership Category 1 - Businesses with 1-2 state-registered employees. Annual Dues - $225Voting Membership Category 2 - Businesses with 3-5 state-registered employees. Annual Dues - $300Voting Membership Category 3 - Businesses with 6-10 state-registered employees. Annual Dues - $350Voting Membership Category 4 - Businesses with 11-15 state-registered employees. Annual Dues - $450Voting Membership Category 5 - Businesses with 16-20 state-registered employees. Annual Dues - $500Voting Membership Category 6 - Businesses with more than 20 state-registered employees. Annual Dues - $575Associate Membership Any person with an interest in the pest control industry. Annual Dues - $350Allied Membership Annual membership for a person or entity associated with the manufacture andsales of pest control products and/or equipment or services to the pest control industry - $400Life Member: Retired individual having served as an authorized representative for an active or associatemember for more than 20 years - No ChargeHonorary Member: Individuals having shown outstanding service to the industry - No Charge