To be filled out and mailed, with check for membership dues, to the:
Florida Transportation Builders' Association, Inc.
P.O. Box 1208
Tallahassee, FL 32302
(850) 942-1404, Fax (850) 942-5632

Contributions (membership dues) may not be deducted as charitable contributions, however, a portion of such dues may be deducted as ordinary and necessary business expense.

CLASSIFICATION: [ ] CONTRACTOR
   [ ]ASSOCIATE [ ] AFFILIATE

FIRM NAME:________________________________________________ 

ADDRESS: _________________________________________________

CITY: ______________________________

STATE: ___ ZIP CODE: _____

PHONE NUMBER: (____)________________

FAX NUMBER: (____)__________________

E-MAIL ADDRESS: ____________________

COMPANY REPRESENTATIVE: __________________________________

TITLE: ___________________________________________________

SIGNATURE: _______________________________________________

DATE OF APPLICATION: _____________________________________