Corporate Membership Application

Main Contact Information
Please complete all information and as you would like for it to appear in Mid-States MSDC publications, mailings and official documents
Principal Representative’s Name

Principal Representative’s Name
Title Company Name
Street Address City State ZIP Code
Mailing Address
Phone
Email*
Fax Number
What were your gross annual sales for the previous fiscal year?*
Checkout
Class Fee
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Credit Card Billing Address:*
Street Address Address Line 2 City State ZIP Code
I would like to add an additional contact
- Yes
I would like to add a third contact
- Yes
Additional Contact
Name

Name
Ttile Company Name
Street Address City State / Province / Region ZIP / Postal Code
Mailing Address

Mailing Address
Phone
Phone
Email

Email
Fax Number

Fax Number
Name

Name
Ttile Company Name
Street Address City State / Province / Region ZIP / Postal Code
Mailing Address

Mailing Address
Phone
Phone
Email*

Email
Fax Number

Fax Number

Company Information
Please provide a detailed description of your company and the products and services provided:
Please provide a detailed description of your company and the products and services provided:
Please list products and services that your company typically purchases:
Please list products and services that your company typically purchases:
Would you be interested in serving on an Mid-States MSDC committee or hosting a Mid-States MSDC meeting or event?
Would you be interested in serving on an Mid-States MSDC committee or hosting a Mid-States MSDC meeting or event?
- Yes
- No

Annual Dues Information
Corporate members pay annual dues in an amount reflected in the table below. Payment can be made via check or credit card. Checks should be made payable to: Mid-States Minority Supplier Development Council.
I would prefer to pay by check
- No
- Yes
Checks should be made payable to: Mid-States Minority Supplier Development Council, and mailed to:
Mid-States Minority Supplier Development Council
2126 North Meridian Street Indianapolis, Indiana 46202

CORPORATE MEMBERSHIP CRITERIA
On July 3, 1980, the Mid-States MSDC Board of Directors approved the bylaws containing the following criteria for Corporate membership in the Mid-States Minority Supplier Development Council:

Corporate Membership Corporate membership shall include those persons, firms, corporations, or divisions, thereof, which from time to time shall represent interests that shall purchase goods and services from minority businesses. Members shall:

1. Attend the meetings of the Mid-States MSDC on a regular basis.

2. Participate in the activities of the Mid-States MSDC. Participation shall include, but is not limited to, service on standing committees, assistance with special projects of the Council, and furtherance of the goals of the Mid-States MSDC for planned minority purchases.

3. Prepare and submit periodic amounts and actual dollar amounts of purchases made by such entities from minority suppliers.

4. Designate from time to time, in writing, a representative who may act for and on behalf of such entity in connections with the affairs of the Mid-States MSDC.

5. Pay annual dues, fees, or assessments as may be from time to time determined by the board of directors of the Mid-States MSDC.

My company believes that private enterprise must make a commitment to the mutual benefit of minority and corporate business. I affirm that I am duly authorized by my company to commit to the payment of dues and the general support of the Mid-States MSDC as pledged herein.
Name Printed

Name Printed
Date
MM slash DD slash YYYY

Date

Corporate Membership Application

Corporate Membership Application

Main Contact Information

Checkout

Additional Contact

Company Information

Annual Dues Information

CORPORATE MEMBERSHIP CRITERIA

Company

Office Hours

Mid-States MSDC Vision