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Please mail or fax to:
IAMOA
9100 Purdue Rd., Ste. 200
Indianapolis, IN 46268
Fax: 317.387.0999
IAMOA Membership
Application/Renewal
Applicant Profile
Company Name: ________________________________
Company Address: ________________________________
Phone Number: ________________________________
Fax Number: ________________________________
Email Address: ________________________________
Web Site Address: ________________________________
Please indicate other memberships:
___ AMOA
___ NDA
___ VNEA
Names of Owner(s): ________________________________
Other Contact Name(s):________________________________
References
Three references must accompany new applications. One reference must be an
Operator:
1. Name:
Address:
Phone Number:
2. Name:
Address:
Phone Number:
3. Name:
Address:
Phone Number:
Please read the following information before completing this application.
Be sure to include all the required details. The absence of any information
may delay your acceptance. Please type or print legibly. Dues must
accompany your application. All applications are subject to approval by
the IAMOA Board of Directors according to the Bylaws.
Qualifications and Dues (Please check all that apply.)
All memberships are based on an annual period beginning January 1st and
concluding December 31st.
___ New application
___ Renewal application
Membership status:
___ Associate
___ General Member
Nature of business:
___ Operator
___ Distributor
___ Other. If other, please provide brief description:
________________________________
________________________________
_________________________________
Number of years in business: _______
I am enclosing my dues for the following membership and understand that
IAMOA will retain $50 to defray costs associated with processing this
application if it is rejected.
___ $350 Operator
___ $500 Distributor
___ $500 Other
Operators, please check all which you own/manage:
___ Jukeboxes
___ Pool Tables
___ Pinball Machines
___ Video Games
___ Darts
___ Foosball Tables
___ Redemption Counter
___ Cranes
___ Vending
___ Kiddie Rides
___ Other. If other, please provide
brief description:
________________________________
________________________________
_________________________________
Acknowledgement
As a condition of my membership in IAMOA, I do accept and endorse the
Bylaws and Code of Ethics of IAMOA and also certify the information on my
application are true and accurate.
_______________________________________
Authorized Signature (Owner)
______________
Date
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