OWQA Membership Application

Print, complete and mail this form as instructed below

The undersigned hereby makes application for Membership and the dues will be as follows:

____Dealer $149.00/Year     Additional Locations May Be Added for $99.00 Each  ____

____Manufacturer / Supplier / Rep $249.00/Year    Additional Factory-Owned Retail Locations may be Added for $99.00 Each ____


FIRM NAME ________________________________________________________________________

ADDRESS _________________________________________________________________________

CITY_______________________________________ STATE______ZIP _______________ PH ______________ FX __________________

EMAIL ____________________________________ Website_________________________________

FIRM REPRESENTATIVE __________________________Email______________________________

ALTERNATE ____________________________________Email_______________________________


The signed applicant, if accepted for membership in the Ohio Water Quality Association, agrees to abide by the OWQA Constitution and By-laws. Make check payable to OWQA and return with application. Or, Payment via Visa, MasterCard and American Express are also accepted.

Type of Card:  VISA __  MasterCard __  American Express __

Card Number _____________________________________________ Expiration Date _____________  Secure Code__________

Name on Card _______________________________________________________________________

Authorized Signature _________________________________________ Billing Zip: _______________

SUBMITTED BY:______________________________________ DATE_________________________


Send back completed form with check or payment information to:
FAX: (937) 278-0317 or
MAIL: 2077 Embury Park Rd. Dayton, Ohio 45414 www.owqa.org

Have Questions? Call 937-278-0308 or owqa@assnsoffice.com


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