Name

Agency, Department or Division

Job Title

Phone Number

Email Address

Address

Please Indicate the type of membership desired: Please Indicate the type of membership desired: A Regular Member shall be employed at least six (6) months in a Government Agency in the operation and maintenance of streets, highways, and public facilities. ($100.00 per individual) An Associate Member shall be an employee of a Utility Company who serves and demonstrates an interest in the purpose and objectives of the Association. ($100.00 per individual) A Vendor Member shall be an individual, partnership, or corporation, or an employee of Same, who demonstrates an interest in the purpose and objectives of the Association. ($100.00 per individual) An Unlimited Agency Membership shall be available to any government agency that meets the eligibility requirements of Regular Membership. This membership includes unlimited individual representatives from the same agency under a single organizational fee. ($1,000.00 per agency)

Membership Status: Membership Status: New Member Renewal Life Member Name Change

Enrollment Year

Referred By:

Certification and Agreement Certification and Agreement I certify that I have reviewed the provided instructions and agree to comply with all requirements set forth in the Constitution and By-Laws of the Arizona Chapter of the Maintenance Superintendents Association. I hereby apply for membership.