b'Midwest Roofing Contractors Association Contractor Membership ApplicationCompany NameCompany AddressCity State Zip CodePhone FaxCompany 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-mailNameAD HERE E-mailTitle NameTitleE-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 EnclosedVisa MasterCard 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 Online7250 Poe Ave., Suite 410 937.278.0317 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'