Independent Rep/Agent Membership Application

Our firm applies for admission as an Independent Rep/Agent in STAFDA. At least 50% of our sales are to distributors serving the construction/industrial markets. We represent a minimum of three STAFDA Associate Members.

I acknowledge that STAFDA annual dues are $350.

STAFDA may charge my Credit Card for the $350 dues.

Company Name

Mailing Address

Street Address

City

State

Postal Code

Country

Phone

Toll Free

Fax

Website

Your Company Contact

Title

Year Your Business Was Founded

Nature of Operations

Total Number of Sales People

STAFDA houses comprise what percent of your total sales volume?

Annual Sales Volume

Our Territory Covers (List of States)

Name of Partners, Owners & Officers

We Belong to These Other National Trade Associations

How did you hear of STAFDA?

Rank Top 5 Choices for Convention Sites

Payment Information

Credit Card Number

Expiration Date /

CVV

First Name

Last Name

Billing Address

City

State

Postal Code

Country

Please answer the following question to help limit spam on our application.

What is Six plus Three? Answer using digits, do not write the word out.