IWQA Membership Application
One Year Membership Dues:  $120.00

(Please print this page, fill in the form, mail or fax the form and payment info to address below)

FIRM NAME ________________________________________________________________________

ADDRESS _________________________________________________________________________

CITY_______________________________________ STATE______ZIP _______________ PH ______________ FX __________________

EMAIL ___________________________________________________ Website_________________________________

FIRM REPRESENTATIVE _______________________________ Email____________________________________________

ALTERNATE _________________________________________ Email_____________________________________________

By the applicants signature, if accepted for membership in the Ohio Water Quality Association, agrees to abide by the Constitution and By-laws. Make check payable to OWQA and return with application. Payment via Visa, MasterCard and American Express are also accepted.

Type of Card:    VISA____    MasterCard____  American Express___

Card Number _____________________________________________ Expiration Date _____________

Name on Card _______________________________________________________________________  Secure Code_________

Authorized Signature _________________________________________ Billing Zip: _______________

SUBMITTED BY:______________________________________ DATE_________________________

Send completed form with check or payment information to:
FAX: (937) 278-0317 or
MAIL: 2077 Embury Park Rd. Dayton, Ohio 45414

Have Questions? Call 937-278-0308 or Iwqa@assnsoffice.com