LOGAN COAL VENDORS ASSOCIATION
2009 Membership Form
Name of Applicant:_______________________________________________________
E-Mail Address: _________________________________________________________
Address________________________________ City ________________ Zip______________
Phone #: _____________________________ Fax #: _________________________________
Name of Company: _____________________________________________________________
Address: _______________________________ City ________________ Zip ______________
State: _________________ Co. Phone#: _____________________ Fax: _______________
Incorporated___________________ Partnership ______________ Other _______________
Owners or Officers Names: 1________________________ 2_________________________
3________________________ 4_________________________
Tax ID # _____________________________________ Number of Employees ____________
Membership Dues $50.00 Annually -- Make Check Payable to: (L.C.V.A.)
_____________________________________________ ________/_______/_______
Applicants Signature Date
PRINTER-FRIENDLY VERSION