IEC Contract Member Registration Form
Company Name
*
Company Website
*
Business Address/Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Point of Contact
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Primary Contact Phone Number
*
Please enter a valid phone number.
Secondary Contact
First Name
Last Name
Secondary Contact Email
example@example.com
Secondary Contact Phone Number
Please enter a valid phone number.
Billing Contact
*
First Name
Last Name
Billing Contact Email
*
example@example.com
Billing Contact Phone Number
*
Please enter a valid phone number.
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Years in Business
*
What type of work does your company provide?
*
Residential
Commercial
Industrial
Maintenance Electricians -- on site
Check those that apply:
Veteran-owned business
Family-owned business
Woman-owned business
Previous IEC member
Business License Issue Date
*
-
Day
-
Month
Year
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
*
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Contractor 1-5
Membership for 1 to 5 contractors
$
1,400.00
Contractor 6-10
Membership for 6 to 10 contractors
$
2,000.00
Contractor 11-20
Membership for 11 to 20 contractors
$
3,550.00
Contractor 21-60
Membership for 21 to 60 contractors
$
4,650.00
Contractor 61-100
Membership for 61 to 100 contractors
$
7,850.00
Contractor 101-150
Membership for 101 to 150 contractors
$
12,550.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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