b'Midwest Roofing Contractors Association Contractor Membership ApplicationCompany NameCompany AddressCity State Zip CodePhoneFaxCompany E-mailCompany WebsitePrimary Contact (will also be billing contact)TitleE-mailReferred by: NameSafety Manager Contact E-mail Other key personnel (will receive important information from MRCA):NameTitleE-mailNameTitleE-mailNameTitleE-mailPrimary MarketCommercial (low slope) Residential (steep slope)BothMembership LevelSilver$795 $ ___________________Gold$1,000(includes $100 donation to MRCA Foundation) $ ___________________Platinum$1,500 (includes $300 donation to MRCA Foundation) $ ___________________Branch$200 $ ___________________Member company affiliation______________________________ TOTALPayment Information (select one)Check EnclosedVisaMasterCard American Express DiscoverName on Card (please print) Account NumberExp Date SignatureReturn form with payment to the Midwest Roofing Contractors Association.Mail or Fax or Call or Apply Online2077 Embury Park Rd. 937.278.0317 800.497.6722 www.mrca.orgDayton, OH.454140% of your membership dues are attributable to nondeductible lobbying expenses as described under Internal Revenue Code Section 162(e). Please consult with your tax advisor regarding deductibility of your membership dues. MRCA15_MalarkeyMemberApp.indd 2 11/13/14 1:56 PM'