Cultured Pearl Association of America, Inc.

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PREMIUM MEMBERSHIP APPLICATION

We (I) respectfully apply for membership in your organization. If elected, we (I) agree to conform to the By-Laws and rules of the Association. Annual dues are $500.00 Upon acceptance of your membership, your dues will be prorated, depending of the date of your acceptance.
Full Name:
Company Name:
Address:
City:
State:
Country:
Zip:
Email*:	*This will be your member login
Phone:
Fax:
Website:

The application firm is a:	Corporation Partnership Sole Proprietorship
List the principles in this business:	1.
	2.
	3.
	4.
This firm is incorporated under the laws of the state of
and has been in business since
Are you listed in the current issue of the Jewelers Board of Trade Red Book?
No Yes
List the names of the individuals entitled to represent you or your firm at meetings of the association and please include their email address.
1. Email
2. Email
3. Email
4. Email

Date:
Firm Name:
Signed by:
Title:

Login password:

Card Type:
Card Number:
CVV Code:
Exp. Date:	/
Promo Code:

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