Member application

Please provide the following contact information.

Name: *

Title:

Company name:

Street address: *

Street address (cont.):

City: *

State/Province: *

Zip/Postal code: *

Country: *

Work phone: *

Fax:

E-mail: *

URL:

Would you like the PCATS Logo for your website?: * YesNo

Choose one of the following membership options: * Class AClass B

Choose one of the following company size options: * Large Company (retailer over 50 stores)Large Company (supplier over $5 M yearly sales)Small Company (retailer 50 stores or less)Small Company (supplier $5 M or less yearly sales)

Choose one of the following company category options: * AssociateConsultantCPGCPG - WholesalerDevice ProviderLotteryMediaMotor FuelsNetworkPartnerPayment SystemsRetailerSolution ProviderSupplier

Please provide the following ordering information.

Billing purchase Order #:

Send Bill to the Attention of:

Address (if different from above):

Address (cont.):

City:

State/Province:

Zip/Postal Code:

Country:

Work Phone:

Fax:

E-mail:

Membership Dues: $10000 Large Company - Class A$5000 Large Company - Class B$2500 Small Company - Class A$1250 Small Company - Class B