NCBPTA Membership Application - North Carolina Bar, Pub and

NCBPTA Membership Application 2013
Complete the form below to apply for membership with the North Carolina Bar, Pub &
Tavern Association.
*Indicates Required Field
* Owner or Agent's First Name_____________________________________________
* Owner or Agent's Last Name_____________________________________________
* Business Name_____________________________________________
* Business Address_____________________________________________
* City__________________________
* State_______________
* Business Phone________________________
* ZIP___________
FAX________________________________
Cell Phone____________________________
* Email Address__________________________
Web Site_____________________________
___ Check here if mailing address is the same as the street address shown above
* Mailing Address________________________________________________________________
* Mailing City________________________* Mailing State_______ * Mailing Zip_____________
* Business Type (check all that apply)
___ Restaurant/Eating Establishment
___ Country Club
___ Private Club
* License Type (check all that apply)
___ On-Premise Malt
Beverage
___ On-Premise
Fortified Wine
___ Brown-Bagging
Permit
___ On-Premise Unfortified
Wine
___ Mixed Beverages
Permit
___ Other
____________________
NC Bar, Pub & Tavern Association | PO Box 25607, Raleigh, NC 27611
Ph: 919-573-1308, Email: info@ncbpta.org
* 2013 Dues Calculation:
NCBPTA Membership Application 2013
$__________________________ Gross Annual Sales for 2011
(*If business was started in 2012, please use your 2012 YTD sales figures,
or the $100 minimum dues, whichever is larger.)
X__________0.001___________ Multiply gross annual sales by this figure
$__________________________ Annual Membership Dues for 2013
(*Maximum of $2,500.00 for 2013)
(*Minimum of $100.00 Membership Dues)
* Method of Payment
Check
Please make check payable to the NC Bar, Pub & Tavern Association or NCBPTA.
OR Pay by Credit Card
Card Type:
Visa or MasterCard
Credit Card Number________________________________ Expiration Date____________
Credit Card CVV____________ (three digit code on back)
Name on Card________________________________________________________
Billing Address________________________________________________________
Billing City___________________________ Billing State__________ Billing Zip__________
Billing Phone Number_________________________
** Signature___________________________________
Please send payment and completed membership application to:
NCBPTA
PO Box 25607
Raleigh, NC 27611
NC Bar, Pub & Tavern Association | PO Box 25607, Raleigh, NC 27611
Ph: 919-573-1308, Email: info@ncbpta.org