CORGA Membership Application

Trade Name:

Applicant's Name:

Address:

City:

State: Zip:

Store Size: Sq. Ft.

Date Started in Business:

Telephone Number: ()

Fax Number: ()

Email address:

Web Page address:

ASSOCIATES IN THE FOOD INDUSTRY

Name:

Address:

Phone:

Name:

Address:

Phone:

 Are you intersted in advertising in our monthly publication?

YES NO

Programs that might interest you:

    Coupons
    Long Distance
    Health Insurance
    Employee Leasing
    Lobbying
    Video Rental
    Money Orders
    Worker's Comp.

Programs that you would consider helpful

MAJOR SUPPLIERS

Name:

Address:

Phone:

Name:

Address:

Phone:

FOR ASSOCIATE MEMBERS

What products or services do you offer?
Payment for dues must be mailed in (by postal mail) for application to be processed. Rate is based upon annual sales. (check only one):

    $75 per year ($0-$2 million in sales)
    $112 ($2 million and above)

Add $38 for each additional store to a maxium of $750 per year.

    $150 per year for Associate Members

Please send check payable to Central Ohio Retail Grocers Association (CORGA), 5310 E. Main St., Suite 104, Columbus, OH 43213-2598. Membership dues and related costs may be deducted as a legitimate business expense. Consult your tax advisor. Enclose one copy of your brochure if available.