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) ................................................................ $325
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 ___________________