ILLBA Vendor Membership Application
Annual Membership Dues: $350
Thank you for your interest in the ILLBA! Company information provided on this form will be added to the ILLBA website.
Company Name
*
DBA Company Name (if applicable)
Name
*
First Name
Last Name
Title
*
Phone Number
Please enter a valid phone number.
Email
example@example.com
ILLBA Representative (if different from above)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Title
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Phone Number
*
Please enter a valid phone number.
Toll-free Number
Please enter a valid phone number.
Company Website
Are you a member of the National Limousine Association (NLA)?
*
Yes
No
Please provide a brief description of the products or services offered by your company.
*
Signature: I certify that the above information is true and correct
*
Print Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: