Membership Application


Please complete and submit the application form below, then follow
the instructions on the next page to submit payment by check or credit card.

Business Information

Name
REQUIRED

Title

Company

Address

City

State

Zip

Area Code/Phone

Fax

E-Mail
REQUIRED

Web Address

Referred By (if any)

Company

 

 

Membership Level

Individual/General Membership   $160.00

 

 

Company Membership   $260.00

Employee Name (list one)

 

 

Qualified Company Membership   $50.00 each
(Company Membership Required)

Employee Name(s)

 

 

Associate Vendor Membership   $500.00

 

 

Youth Member   $25.00

 

 

Payment Method

 

 

I will pay by: 

 Check          Credit Card or PayPal

 

 

CAPABILITY PRIDE INTEGRITY

© Copyright 2007-2017 Rhode Island Independent Contractors & Associates. All rights reserved.
PO Box 233 Exeter, RI 02822 (401) 785-1830
RIICA is a 501(c) 6 non-profit organization.

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