CSAA's 2005 Membership Application for North American Member

2006 Membership Application for North American Member
(formerly Regular Member)

We hereby apply for membership in the Central Station Alarm Association. If our application is approved, we agree to observe the Bylaws of the Association and give due consideration to all lawful activities that will contribute to its advancement and growth.

Contact Person / Official Representative __________________________________________

Title ________________________________________________________

Company Name _______________________________________________

Address ______________________________________________________

City/State/Zip _________________________________________________

Phone Number ________________________ Fax Number _________________________

E-mail ________________________________ Web site _____________________________

Date of Listing of UL Central Station __________

UL Project Number (For Applicant Members Awaiting UL Listing) ________________________

Is company actively engaged in installing and servicing alarm systems? ¨ Yes ¨ No

Is this company owned or controlled by another organization? ¨ Yes ¨ No

If yes, please complete the following:

Name of Controlling Organization __________________________________________________

Address ______________________________________________________________________

All applicants must be sponsored by one CSAA North American (formerly Regular) Member in good standing with the Association.

Sponsor Name ____________________________________ Telephone No. ______________________

Sponsor's Company Name ______________________________________________________________

Address _____________________________________________________________________________

CSAA North American Member Membership Dues Structure

Amount of check enclosed (check appropriate category on the table):

	Company Gross Revenues	Annual Dues
____	Less than $3 million *First year's dues. Second year's dues will be $1,000; third year's dues will be $2,215	$500*
____	At least $3 million, but less than $4 million	$2,530
____	At least $4 million, but less than $6 million	$2,645
____	At least $6 million, but less than $15 million	$2,875
____	At least $15 million, but less than $30 million	$4,028
____	At least $30 million, but less than $55 million	$5,750
____	At least $55 million, but less than $120 million	$8,050
____	At least $120 million, but less than $200 million	$11,500*
	*Over $200 million: $4,000 for each additional $200 million in revenue, with no cap.	_______

Please return this form with your check for one year's dues to: CSAA, 440 Maple Avenue East (#201), Vienna, VA 22180. Dues apply to the calendar year. For more information, contact Becky Lane, CSAA's Director of Membership at 703/242-4670, Ext. 18 or memberservices@csaaul.org.

Privacy Statement: Any financial information requested on this form will be disclosed only to CSAA staff for the sole purpose of setting the appropriate dues. This information will not be made available to members of the association or any other parties.

The above information is submitted for the purpose of obtaining membership in the Central Station Alarm Association, and is warranted to be true and correct. Permission is hereby granted to CSAA to request information from the above-named sponsor or any other source. We understand that one year's fees are due and payable in advance in accordance with the terms that shall then be in effect, or otherwise directed by the Board.

Authorized Signature ________________________________

Title __________________________ Date ______________