1. Company__________________________________________Phone ( )______________ Fax ( ) _____________

2. Address___________________________________________City____________________State_______ Zip_______

3. Owner’s Name______________________________Home Phone( )_________________Yrs in business _________

4. Web Site __________________________________ E-Mail Address _______________________________________

5. State Senator_______________________________ State Assemblyman____________________________________

6. What other related associations do you belong to?______________________________________________________

7. What body of water are you accessible to?____________________________________________________________

8. Are you a (check all that apply) ____Manuf. _____Dist. _____ Retailer _____ Broker _____ Marina _____ Service Yd.

9. Other business conducted ___________________________________________________________________

10. Marina Facility # wet slips _____ # dry slips _____ # storage _____ fuel _____ pump-out _____ qk launch _____

11. Products sold: Boat Lines _______________________________________________________________________

Motor Lines _______________________________________________________________________

Trailers _______________________________________________________________________

Misc. _______________________________________________________________________

12. Supplies sold: Paint_____ Hdwre_____ Electronics ____ Safety Equip_____ Ski Equip ____ Canvas ____ Apparel ____

Other _____________________________________________________________________

13. DMV Facility # ____________________________ Expiration Date ________________________

I hereby make application for membership in the Eastern New York Marine Trades Association and agree to abide by the bylaws. I understand that Regular Membership automatically includes membership in the Empire State Marine Trades Association and by dues are through my local association. Once accepted as a Regular Member I shall be entitled to all membership privileges of the association according to the bylaws.

_____ I am applying for Regular Membership and have enclosed a check for $375 which includes

a one-time $100 application fee

_____ I am renewing my membership and have enclosed a check for $275 for Regular Membership

_____ I am a member of ESMTA through another local MTA and have enclosed a check for $125 for Regular Membership

I am a member in good standing of _________________________________(local MTA)

_____I do not want regular membership in ENYMTA or ESMTA and have enclosed a check for $125 as Supportive Member.

I authorize the following representative(s) to attend meetings and vote

_____________________________________________ _____________________________________________

Signed by: ___________________________________________________________Date ________________