FOOD INDUSTRY ALLIANCE OF NEW YORK STATE, INC.

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

Independent Membership Application

Company Name: ______________________________________

Contact Name: ______________________________________

Street Address: ______________________________________

City/State/Zip: ______________________________________

Telephone: _______________________________________

Fax: _______________________________________

E-Mail: ________________________________________

Please enter your Annual Sales Volume for most recently completed year __________

Please calculate and enter your dues based upon the following schedule ___________

DUES SCHEDULE FOR INDEPENDENT GROCERY STORES
BASED UPON ANNUAL GROSS SALES IN NEW YORK STATE

Total NYS Sales	Annual Dues
Below $1 million	$200
$1,00,001-$5 million	$390
$5,00,001-$10 milllion	$520
$10,000,001-$15 million	$650
$15,000,001-$25 million	$775
$25,000,001-$50 million	$1290
$50,000,001-$100 million	$1950
$100,000,001-$250 million	$3240
Over $250 million	$3500

How many stores does this company represent in NYS? __________

How many employees? __________

What company is your wholesaler? ____________________

If this store is a franchise operation, what company is the franchiser? ____________________

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