Welcome to the International Association of Operative Millers

Application for (check one):
Active Membership Junior Membership Associate Membership

GENERAL INFORMATION:

Last Name:
First Name:
Middle Name:
Fourth Name:
Company Name:
Company Address:
Company City:
Company State:
Company Zip/Postal Code:
Company Country:
Company Phone:
Company Fax:
E-Mail:
Position in Company:
Residence Address:
Residence City:
Residence State:
Residence Zip/Postal Code:
Residence Country:
Home Phone #:

To which address do you prefer your IAOM mail delivered?
Business Address Home Address


BUSINESS/SERVICE INDUSTRY EXPERIENCE INFORMATION:

Company Name:
From:
To:
Position:

Company Name:
From:
To:
Position:

Company Name:
From:
To:
Position:

Company Name:
From:
To:
Position:

ADVANCED EDUCATION INFORMATION (education beyond high school):

Name of Institution:
Location:
Degree:
Date Graduated:

PAYMENT INFORMATION:
VISA MASTERCARD AMERICAN EXPRESS
Card #:
Expiration Date:
Name as it appears on card:

I, the undersigned, do hereby make application for membership, and agree to comply with all laws, rules, and regulations of the IAOM. I hereby tender $ in U.S.A. funds drawn on a U.S.A. bank (Active or Associate - $175.00 Junior Active - $30.00), to be returned to me if my application is rejected. I agree to pay annual dues in like amount, or such sum as may be established by the Board of Directors in the future.

Signature Date

Mail application form with Check or Money Order (in U.S. funds, drawn on a U.S. Bank), made payable to: IAOM, or use
American Express, MasterCard, or Visa credit card.

Revenue ACT (H.R. 3545), Section 10701 (a) Remittances to the IAOM are not deductible as charitable contributions for federal USA income tax purposes. However, dues payments are deductible by members as an ordinary and necessary business expense.

IAOM Spotlight

	International Association of Operative Millers 5001 College Blvd., Suite 104, Leawood, Kansas 66211 USA • Phone: 913 338-3377 • Fax: 913 338-3553 • info@iaom.info