| Contact Information | |
| Company Name | |
| Company Address |
|
| Applicant's Name | |
| Home Address |
|
| Business Phone | |
| Business Fax | |
| Cell Phone | |
| Website |
|
| Email Address | |
| Membership Class (Please check one) | |
| Regular ($300 + 21 tax = $321) Landscape Professional |
|
| Associate ($400 + 28 tax = $428) Industry Related |
|
| Student ($150 + 10.50 tax = $160.50) Full time student |
|
| Dues payable to the PLANJ are not deductible as a charitable contribution for federal income tax purposes, but are deductible as ordinary business expense. | |
| Insurance Information (Certificate must be provided) | |
| Liability Policy # |
|
| Workers Comp Policy # |
|
| Sales Tax ID# | |
| Pesticide License# |
|
| Personal Reference and PLANJ Member Sponsor | |
| Name |
|
| Phone | |
| Name | |
| Phone |
|
| Credit Card Information (Required if paying by credit card) | |
| Visa/Master Card# | |
| Expiration Date | |
| Billing Zip Code | |
| Signature | |
| I hereby apply for membership and agree to uphold the principles as stated in the Bylaws, Guidelines and Mission Statement of the Professional Landscape Alliance of New Jersey. | |
| Signature |
|
