Membership Application

Membership acceptance is subject to approval by Board of Directors. Please fill in all fields of the form that apply!

(All fields required.)

Company Name
Company Representative
Street Address
City
State or Province
ZIP or Postal Code
Country
Phone
Toll-free Phone
Fax
Email
Website
Primary Nature of Business
Brief Description of Your Business
Business Type

	Corporation
	DBA
	Professional
	Other (Explain Below)

Explain Other
Principal Owners/Officers
Years Engaged in Business
Are you Interested in joining one of the following divisions of NASSCO?

	IPBA (International Pipe Bursting Association)
	ICGA (Infiltration Control Grouting Assocation)
	TEMA (Trenchless Equipment Manufacturers Association)

How did you hear about NASSCO?
How can NASSCO best serve the sewer rehabilitation industry?
How can NASSCO best serve you?
Are you interested in serving on any NASSCO committees?

	Yes
	No

Did a NASSCO Member refer you? If Yes, who?
Click here to view the NASSCO Pledge Statement

Approval

I confirm that I have read and accept the attached Pledge Statement and that the information above is correct to the best of my knowledge. Checking this box is equivalent to my signature.

Membership Type
Add-on ICGA Membership

* ICGA Associate members are NASSCO members who play a peripheral role in grouting or may only receive minimal benefit from expanding the awareness of grouting, but would like to participate due to their background or past experience. Grouting contractors, Grouting equipment suppliers, and chemical group suppliers will not be considered for this category. ICGA Committee approval required.

Add-on IPBA Membership
Add-on TEMA Membership

* Note: If you are interested in TEMA, please email Irv Gemora at director@NASSCO.org or call 410-486-3500.

Credit Card Type
Card Number
Cardholder Name
Total Amount Authorized

$450.00

Is NASSCO For You?
Membership Dues
Membership Application

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