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Onine Member Application
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1 - Company Information
Company Name:
(Required)
Mailing Address:
City, State, Zip:
Street Address (if different from above):
City, State, Zip:
Contact Member Name & Title: (this will be your "Voting Representative")
Direct Email:
Direct Phone:
Direct Fax:
General Phone:
General Fax:
Website:
This form was completed by: (name & date)
(Required)
2 - Additional Contact Names
Please list any individuals below, that you wish to be included in the Membership Directory. Please include address information only if it is different than SECTION 1 above. Also include the individual's email address, and direct phone number if applicable.
Contact #2:
Check here if individual should receive correspondence:
Yes
Contact #3:
Check here if individual should receive correspondence:
Yes
Contact #4:
Check here if individual should receive correspondence:
Yes
3 - Annual Dues
Annual Dues (Based on sales of Parts and Accessories). Please Select one: (data remains confidential)
$0 to$500,000 - Dues $695
500,000 to 1 Mil - Dues $1,195
1+ to 5 Million - Dues $2,350
5+ to 10 Million - Dues $4,395
Greater than 10 Mil - Dues $6,750
Distributor Member - Dues $995
Affiliate Member - Dues $995
4 - Business Information
Marketing Region(s):
Year Founded:
MM slash DD slash YYYY
Number of Employees:
Please tell us about your company:
Number of locations/branches:
Please select one:
Manufacturer
Distributor
Independent Manufacturers' Representatives (IMR)
Other
If Other, please explain:
Other associations of which your company is a member:
The three major products categories your company sells, in order of importance:
#1:
#2:
#3:
Major brands your company distributes:
Briefly indicate what benefits you expect from your OPPAA membership:
Please use the box below for any General Comments you may wish to make:
Have you read, and do you agree to adopt the limited warranty and product liability policies of OPPAA?
Yes
No
Do you promise to abide by the Code of Ethics as prescribed by OPPAA?
Yes
No
Do you attest that all information provided here is true and accurate, to the best of your knowledge?
Yes
No
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Phone
This field is for validation purposes and should be left unchanged.
