Regular Membership Application Form

Georgia Electronic Life Safety & Systems Association (GELSSA)
Standard Membership Application

* indicates required fields
Company Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Low Voltage License Number (Please attach below)
Please attach low voltage license *

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Primary Contact Information
Name *

First Name Last Name
Title *
E-mail *
Work Number *

Area Code Phone Number
Cellular Number

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Secondary Contact Information
Name

First Name Last Name
Title
E-mail
example@example.com
Work Number

Area Code Phone Number
Cellular Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Billing Information
Company Name *
Billing Contact Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
example@example.com
Phone Number *

Area Code Phone Number
How did you hear about Gelssa?
Company Data
Please indicate all products and services offered by your company:

Access Control Fire Alarms Intrusion Alarms Closed Circuit TV Home Automation Monitoring Equipment Communication Equipment Consulting Service Monitoring- Burglary and/or Fire
By completing and submitting this application, I hereby authorize the Georgia Electronic Life Safety & Systems Association (Gelssa) to send me pertinent documents and associatin and industry information via e-mail at all e-mail addresses listed on this application. I recognize that such documents include, but are not limited to, billing statements, registration forms, GELSSA member communications, and official letters. I understand that granting this permission is essential to the association's ability to communicate with me effectively.
All information contained in this application is true and accurate and the undersigned acknowledges that false information can result in the denial of acceptance of this application. Upon approval, the undersigned agrees to abide by and subscribe to the Bylaws, Code of Ethics, and Antitrust Statement of the Georgia Electronic Life Safety & Systems Association.
Signature *

Clear
Signature Date *

Month Day Year
Annual membership dues are $150.00 and will be billed to you upon approval of membership.
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Standard Membership Application