Connecticut Fire Equipment Mechanics Association

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[Membership Application]

Connecticut Fire Equipment Mechanics Association

Membership Application

Date:____________

Name:___________________________________________________________________

Address:_________________________________________________________________

City:_____________________________________________________________________

State:____________________________________________  Zip Code:_______________

Home Phone:__________________________ Home Fax:__________________________

Company Name:___________________________________________________________

Title:_____________________________________________________________________

Company Address:_________________________________________________________

City:______________________________________________________________________

State:____________________________________________ Zip Code:________________

Work Phone:___________________________ Work Fax:__________________________

E-Mail Address:_________________________ Home E-Mail:_______________________

Mailing Sent to:     Work Address_________        Home Address________

Membership Type:   Active_________        Corporate__________

Annual Membership Dues:        Active--$25.00        Corporate--$100.00

Dues Enclosed:        Yes______        No_______

Print and mail to:  Connecticut Fire Equipment Mechanics Association

                                   3050 Main Street

                                   Rocky Hill, CT. 06067