Contractor Member Application

CONTRACTOR MEMBER APPLICATION

WESTERN COLORADO IEC PO Box 1052 Glenwood Springs, CO 81602 em:wceic@qwestoffice.net ph: 970.945.1079
The below applicant for membership in the Western Colorado IEC shall be a licensed contractor. The applicant states that he/she is in accord with the stated ethics of this Association and agrees to abide by the Bylaws and authoritative actions of its Board of Directors. The applicant agrees to supply below requested references. He/she also agrees to pay this Association all dues, assessment, and fees when invoiced , due upon receipt.
COMPANY NAME*
Name of Your Company
WEBSITE*
https://www.yourcompany.com
EMAIL*
example@example.com
MOBILE PHONE*
Please enter a valid phone number.
COMPANY PHONE*
Please enter a valid phone number.
FAX
Please enter a valid phone number.
MAILING ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COMPANY OWNERS & OFFICERS

Please list the names and titles of each company owner and/or officer.
FULL NAME & TITLE*

NameTitle
STATE LICENSE #*
MASTER ELECTRICIAN #*
FULL NAME & TITLE

NameTitle
STATE LICENSE #
MASTER ELECTRICIAN #
WESTERN COLORADO IEC DUES

*If assistance is needed, please call the office at 970.945.1079 Or email at wciec@qwestoffice.net
# OF FIELD EMPLOYEES
MONTHLY DUES $$
TOTAL $$ OF FEES & DUES*
*Reminder to add the $50 Processing Fee as mentioned above. ALL FEES AND DUES ARE PAYABLE TO WESTERN COLORADO IEC.
Your company, determine which range corresponds to the # of field employees for monthly dues.

Min. Dues $99.00 / Max. Dues $498.00
Membership Fees & Monthly Dues
Signature*

Clear
By entering your name you are approving this submission and all fees assciated with it.
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

CONTRACTOR MEMBER APPLICATION

COMPANY OWNERS & OFFICERS

WESTERN COLORADO IEC DUES

Your company, determine which range corresponds to the # of field employees for monthly dues.