MEMBERSHIP APPLICATION

Company Name _________________________________________________________________________________
Member Name __________________________________________________________________________________
Address _______________________________________________________________________________________
City ___________________________________________________________________________________________
State _________________________________________ Zip ____________________________________________
Phone ( _______ ) ______________________________ Fax ( _______ ) _________________________________
Email Address __________________________________________________________________________________
Spouse's Name _________________________________ (Contractor Member Only) Date of Birth ______________
Sponsor _______________________________________________________________________________________

(Type of Business)
DI Drainage/Irrigation OSW On Site Waste Treatment
EC Erosion Control PA Paving
EMC Earthmoving/Land Cleaning R Reclamation
EXG Excavating/Grading PD Ponds or Dams
LL Land Leveling SEP Septic Systems
LS Landscaping TH Trucking or Hauling
ODW Open Ditch Work TW Terraces or Waterways
SA Dealer, Service, Government Agency, Consultant, Insurance Agency

Application is for (Check One)

Active Member (Annual Dues) ................................................................ $300
Active Land Improvement Contractor.
Associate Member (Annual Dues) ................................................................ $400
Person or companies manufacturing or selling materials, equipment or services to active members.
Affiliate Member (Annual Dues) ................................................................ $75
Person(s) or Employees affiliated with another MLICA Member.
Supporting Member (Annual Dues) ................................................................ $100
Person(s) or companies interested in MILICA

Signature_______________________________________________________ Date ___________________________