Contractor Membership Registration Form

IEC Contract Member Registration Form
Company Name*
Company Website*
Business Address/Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Point of Contact*

First NameLast Name
Primary Contact Email*
example@example.com
Primary Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact

First NameLast Name
Secondary Contact Email
example@example.com
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Billing Contact*

First NameLast Name
Billing Contact Email*
example@example.com
Billing Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years in Business*
ResidentialCommercialIndustrialMaintenance Electricians -- on site
Veteran-owned businessFamily-owned businessWoman-owned businessPrevious IEC member
Business License Issue Date*

DayMonthYear
Date
Kentucky CE License #*
Main reason for becoming a member*
Please list at least two business references, including name, company name, and phone number*
Is there anything about your business that you feel we should know while reviewing your application?

My Products*

Contractor 1-5

Membership for 1 to 5 field employees

$1,500.00

Contractor 6-10

Membership for 6 to 10 field employees

$2,150.00

Contractor 11-20

Membership for 11 to 20 field employees

$3,800.00

Contractor 21-60

Membership for 21 to 60 field employees

$5,000.00

Contractor 61-100

Membership for 61 to 100 field employees

$6,450.00

Contractor 101-150

Membership for 101 to 150 field employees

$8,350.00

Contractor 151-200

membership for 151-200 field employees

$13,050.00

Total

$0.00

IEC Contract Member Registration Form