Please print this application form, complete, and send to: New England Livery Association PO Box 842, Durham, NH 03824 Fax: 866.616.6352 E-mail: info@nelivery.org Need help? Call: 866-736-NELA (6352), or email: info@nelivery.com For your security, please do not send this form via email with your credit card information. < ------------------------------------------------ > Application for NELA Regular Membership To The Board of Directors, New England Livery Association: I/We hereby apply for membership in the New England Livery Association and any benefits that may derive therefrom. I/We pledge to abide by the New England Livery Association Principals of Professional Code of Ethics. I certify that the information presented in this application is true and accurate. Company Name: _________________________________________________ Contact Person: _____________________________________________________ Address: ___________________________________________________________ __________________________________________________________________ City : __________________________________ State: _________________________________ Zip Code: ______________________________ Phone Numbers - please include area codes: Business: ___________________ Other: _____________________ Fax: ______________________ Email address (if applicable): ______________________________________________ Business web site address (if applicable): _____________________________________ Vehicle Information Please list number of each type of vehicle in your fleet. Sedans:__ Station Wagons:__ Hearses:__ 4-6 Passenger Limos:__ 8-10 Passenger Limos:__ 6-8 Passenger Vans:__ 10-15 Passenger Vans:__ 16-29 Passenger Busses:__ 29-53 Passenger Busses:__ Other:__ Permits The Interstate Commerce Commission & Department of Transportation require that authority be obtained for business conducted over state lines. Would you like to receive additional information about applying for this authority? Yes:__ No:__ My Company has an ICC Authorization. Yes:__ No:__ If yes, my ICC number is:_____________ My Company meets appropriate State/City License & Insurance Requirements. Yes:__ No:__ My Company possesses appropriate & required airport permits Yes:__ No:__ Membership Schedule Membership dues and contributions are based upon number of company vehicles. Total number of vehicles: __ $125.00/year 1-5 vehicles __ $175.00/year 6-9 vehicles __ $225.00/year 10-19 vehicles __ $345.00/year 20-49 vehicles __ $600.00/year 50 or more vehicles Total # of vehicles for which this application is submitted: ___________________ Dues payable: $_____________ Our check is enclosed for $______________ or Charge to (check one): __ Mastercard __ VISA __ American Express __ Discover Card #: __________________________________________ Expiry Date: _______________________________________ Please State briefly why you wish to join NELA: ______________________________________________ ___________________________________________________ ___________________________________________________ Your credit card will not be charged until your application is accepted. Membership dues and contributions are tax deductible to the extent permitted by law. Signature: ______________________________________________ Print Name: _____________________________________________ < ------------------------------------------------ > On behalf of the Board of Directors, thank you for joining the New England Livery Association. Larry White, President