PARTS Membership Application

*=Required Fields

* Company Name

* Contact Person (to be listed on web membership directory)

* Street Address

* City * State * ZIP

* Directions to Your Business from the closest major highway:

* Federal Tax ID #
 PA Sales Tax #
* Phone # (Please include your area code)
 Toll Free #
FAX # (Please include area code)
 * E-mail

* Owner's Name

* Home Address

* City * State * ZIP

Recommended/Nominated by

NATIONAL & LOCAL MEMBERSHIPS:

WPADRA
Eastern
SW Phila.
ISRI
None
Other:

INFORMATION ABOUT YOUR BUSINESS

* Date Started
 Specialize In
* # Full-time Employees
 * # Part-time Employees
# of Rollbacks
 # of Wreckers

DO YOU HAVE ANY OF THE FOLLOWING AT YOUR BUSINESS? (Check all that apply.)

FAX
Computers
Internet

DO YOU HAVE ANY OF THE FOLLOWING LICENSES? (Please check all that apply)

WL Tag
PA Salvor
RT Tag
Used Car Dealer
Highway Beautification