MEMBERSHIP APPLICATION

Company Name ______________________________________________________________________________
Member Name _______________________________________________________________________________
Address ____________________________________________________________________________________
City ________________________________________________________________________________________
State ________________________________________ Zip __________________________________________
Phone ( _______ ) ______________________________ Fax ( _______ ) _______________________________
Email Address _______________________________________________________________________________
Spouse's Name _______________________________ (Contractor Member Only) Date of Birth ____________
Sponsor ____________________________________________________________________________________

Please check all categories that best describe your business.
CH Concrete/Hardscaping OD Open Ditch Work/Dredging
CR Crane Service PD Ponds or Dams
DB Directional Boring RP Roads/Paving
DW Drainage/Water Mgmt/Irrigation SP Site Prep/Demolition 
EM Earthmoving/Grading/Land Leveling SS Septic Systems /Onsite Wastewater Treatment
EX Excavating/Land Clearing  TH Trucking/Hauling
GR Gravel/Rock/Sand Production TW Terraces/Waterways
LS Landscaping/Seeding/Sod  UU Undergound Utilities

Application is for (Check One)
Active Member (Annual Dues) ................................................................ $325
Active Land Improvement Contractor.
Associate Member (Annual Dues) ................................................................ $400
Person or companies manufacturing or selling materials, equipment or services to active members.
Affiliate Member (Annual Dues) ................................................................ $75
Person(s) or Employees affiliated with another MLICA Member.
Supporting Member (Annual Dues) ................................................................ $100
Person(s) or companies interested in MILICA

Signature_______________________________________________________ Date ___________________