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

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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