NCBPTA Membership Application - North Carolina Bar, Pub and
NCBPTA Membership Application 2013 Complete the form below to apply for membership with the North Carolina Bar, Pub & Tavern Association. *Indicates Required Field * Owner or Agent's First Name_____________________________________________ * Owner or Agent's Last Name_____________________________________________ * Business Name_____________________________________________ * Business Address_____________________________________________ * City__________________________ * State_______________ * Business Phone________________________ * ZIP___________ FAX________________________________ Cell Phone____________________________ * Email Address__________________________ Web Site_____________________________ ___ Check here if mailing address is the same as the street address shown above * Mailing Address________________________________________________________________ * Mailing City________________________* Mailing State_______ * Mailing Zip_____________ * Business Type (check all that apply) ___ Restaurant/Eating Establishment ___ Country Club ___ Private Club * License Type (check all that apply) ___ On-Premise Malt Beverage ___ On-Premise Fortified Wine ___ Brown-Bagging Permit ___ On-Premise Unfortified Wine ___ Mixed Beverages Permit ___ Other ____________________ NC Bar, Pub & Tavern Association | PO Box 25607, Raleigh, NC 27611 Ph: 919-573-1308, Email: [email protected] * 2013 Dues Calculation: NCBPTA Membership Application 2013 $__________________________ Gross Annual Sales for 2011 (*If business was started in 2012, please use your 2012 YTD sales figures, or the $100 minimum dues, whichever is larger.) X__________0.001___________ Multiply gross annual sales by this figure $__________________________ Annual Membership Dues for 2013 (*Maximum of $2,500.00 for 2013) (*Minimum of $100.00 Membership Dues) * Method of Payment Check Please make check payable to the NC Bar, Pub & Tavern Association or NCBPTA. OR Pay by Credit Card Card Type: Visa or MasterCard Credit Card Number________________________________ Expiration Date____________ Credit Card CVV____________ (three digit code on back) Name on Card________________________________________________________ Billing Address________________________________________________________ Billing City___________________________ Billing State__________ Billing Zip__________ Billing Phone Number_________________________ ** Signature___________________________________ Please send payment and completed membership application to: NCBPTA PO Box 25607 Raleigh, NC 27611 NC Bar, Pub & Tavern Association | PO Box 25607, Raleigh, NC 27611 Ph: 919-573-1308, Email: [email protected]
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