CSA Associate Membership Application.2

Associate Membership Application • Connecticut Subcontractors Association

Annual Dues = $500

Company

Address*

Mailing Address

City* State*Zip*

Phone

Fax..

Website Address

Primary Name

Title

Email Address

Secondary Name

Title

Email Address

Please check primary business: (Please check all that apply.)

Accountant Bonding Financial Services Insurance Legal Service Other

Other, please describe

Please describe the products or services.

What is your reason for joining CSA? (Please check all that apply.)

Access/Exposure	Directory	Discounts	Networking
Newsletter	Free Tabletop	Other

Other, please describe

Who sponsored, referred or recommended you to CSA?

Total

Payment* Master Card Visa AMEX

First Name

Last Name ..*

Account Number

Exp. Mo.*Exp. Yr.*Security #*

Billing Address

Email*

CSA dues are not deductible as a charitable contribution for federal tax purposes, but may be deductible as a business expense up to 81%.