Name ___________________________________________________________

Company ________________________________________________________

Address _________________________________________________________

City/State/Zip ____________________________________________________

Phone _______________________________________

Fax __________________________________________

E-mail _______________________________________

Recommended by _______________________________________________

Individual Contractor (Well Drilling and/or Pump Installer):  $220

Manufacturer/Supplier:  $250

Associate(A Non-voting membership for any person in government or educational positions):  $50

_____ Additional persons may be added to our mailing list to receive all membership correspondence at a cost of $50 each. Please provide the names of any additional persons for this purpose only below.

1.  __________________________________________________

2.  __________________________________________________

Please print out and send completed application with check payable to: