Associate Membership Application

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

* indicates required fields
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Contact Information
Name*

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

Area CodePhone Number
Cellular Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Contact Information
Name

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

Area CodePhone Number
Cellular Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Billing Information
Company Name*
Billing Contact Name*
Address*

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
How did you hear about Gelssa?
Company Data
Access ControlFire AlarmsIntrusion AlarmsClosed Circuit TVHome AutomationMonitoring EquipmentCommunication EquipmentConsulting ServiceMonitoring- Burglary and/or FireOther
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*

MonthDayYear
Annual membership dues are $250.00 and will be billed to you upon approval of membership.
Should be Empty: