IMASD Membership Application

Current Email:          


   Company:         
   First Name:         Last Name: 
   Street:              
   City:                  
   State/Province:    Zip/Postal: 
   Country:             
   Voice Phone:        Ext: 
   Fax Phone:        


   Will you be working with a Technical Assistant?
   (You may leave blank if you are not working through an assistant.)
   Assistant's Name:     
   Assistant's E-mail:    
   Assistant's Voice Phone:    Ext: 

    Check this box if you want us to provide a Technical Assistant for you.


*****************OPTIONAL*******************************

   If you have already registered your own domain name, what is that name?
     
   

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Do you have a preference of a username?
This will be used as your company website name, 
i.e. surplus.net/mycompanyname (all in lowercase).
Please specify what you would like.  
Remember, the easier the name, the easier for customers to remember your web address.
        
I would like my username to be:

*We cannot guarantee the username you ask for, in case someone else is 
already using that, but will try our best to accommodate you.

Do you have a preference of a password?

I would like my password to be:


**********************************************************

   Description of your products and services:
   This is for Search Engines, your website, and the Surplus Dealers Directory.
   

   Primary Products:
   Example: tools Levis transistors computers videos stuff. These key
   words are for Search Engines. Put them in the order of importance.
   


   Questions or other comments:
   For example, tell us where you heard about IMASD.
   

ONGOING IMASD FEES:

All IMASD Members are required to pay a one time setup fee of $100, in
addition to $25 per month dues.

 (Choose one)
     I choose No 1: FULL MEMBERSHIP for a one time payment of $3,000 (or call to
negotiate).

     I choose No 2: LEASE to OWN OPTION. Please call me to work out payment schedule.

     I choose No. 3: Three Month Trial Option.  $275.00 total
     (includes set up fee and IMASD dues)

     I choose No 4: Monthly Rental ($75 per month)
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PAYMENT INFORMATION:

This form will allow you to submit credit card or banking information on-line,
although nothing is deducted on line.  However, if you are uncomfortable
with submitting this information here,
type "I'll pay by fax" in the Name on Card field below and
leave the rest of the fields blank.



Charge my credit card:


Name on Card: 
Card Number:    Exp. Date: 


or


Electronic Funds Transfer: (US Banks only. Read these numbers from your checkbook.)
 Signatory Name:         
 Bank Name and Location: 
      Route Number:    |:|:
      Account Number:    


   When the information you have entered above is correct,
   press the SUBMIT button below.