FOOD INDUSTRY ALLIANCE OF NEW YORK STATE, INC.

Headquarters · 130 Washington Avenue · Albany, NY 12210
Telephone 518-434-1900 · Fax 518-434-9962

Chain Supermarket Membership Application

Company Name: ______________________________________

Contact Name: ______________________________________

Street Address: ______________________________________

City/State/Zip: ______________________________________

Telephone: _______________________________________

Fax: _______________________________________

E-Mail: ________________________________________

For chains with New York sales volume less than $500 million annually, the dues formula is as follows:

Headquarters Fee: $6,250

Plus $6.50 per $1 million of sales: ___________

TOTAL DUES: __________

For chains with New York sales volume exceeding $500 million annually, the dues formula is as follows:

Headquarters Fee: $6,750

Plus $5.50 per $1 million of sales: __________

TOTAL DUES: __________

Please mail your dues, accompanied by this application to our ALBANY office
at
130 Washington Avenue
Albany, New York 12210

IN ACCORDANCE WITH THE PROVISIONS OF THE OMNIBUS BUDGET RECONCILIATION ACT OF 1993, 77% OF YOUR MEMBERSHIP DUES FOR CALENDAR YEAR 2002 ARE DEDUCTIBLE FOR FEDERAL TAX PURPOSES

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To better meet the needs of its extensive membership, FIA maintains two offices:
*Headquarter Office*		Metro Office
130 Washington Avenue Albany, NY 12210 Telephone 518-434-1900 Fax 518-434-9962		1234 Summer Street 4th Floor Stamford, CT 06905 Telephone 203-977-2438 Fax 203-348-0196
DIRECTIONS TO FIA HEADQUARTER OFFICES