Application for Membership for NCCI

I hereby make application for membership in NCCI – The Coal Institute, Inc., in accordance with the By Laws and by personal endorsement of the two member companies listed below.

Applicant Information:

Company

Name

Title

Address

City

State

Zip

Type of Company

Producing Sales Carrier Consumer Other

Names/Titles of company officers

1.
2.
3.
4.
*5.
*6.

You must have two people from member companies endorse you. Include their name and company information here.
1.
2.

* MEMBERSHIP DUES Annual Dues are $300.00/Company for a four person listing in the Membership Directory and $500.00/Company for a five or more person listing in the Membership Directory per fiscal year (October 1 through September 30).

I intend to pay by: credit card check

Billing Information:

Name On Card:

Select Credit Card Type:

Billing Address For Card:

Card Number:

Street 1:

Expiration Date: month/year

Street 2:

City:

State:

Zip Code:

Country:

Renewal Information:

Enter the name and address of the person who should receive the Membership Renewal Notice.

Name:

Mailing Address:

Telephone:

Fax:

Website:

Individual Information:
Please provide information for the individuals to be listed under the above address.
	Name	Title	Telephone	Fax	Email
1.
2.
3.
4.
5.
6.

Other Office:

Mailing Address:

Office Type:

Telephone:

Fax:

(Other Office) Individual Information:
Please provide information for the individuals to be listed under the other office address.
	Name	Title	Telephone	Fax	Email
1.
2.
3.
4.
5.
6.


To register by mail or courier, send your check made payable to NCCI - The Coal Institute to :

U.S. Postal Service: Ms. Karen Smith P.O. Box 3672 Pikeville, KY 41502	For Fed-Ex or UPS Shipments: 284 Weddington Branch Road Pikeville, KY 41501