This is not an online form. Please print, fill out and send with remittance to:

The Powder Coating Institute
2121 Eisenhower Avenue
Suite 401
Alexandria, VA 22314

_____Yes, I would like to join PCI as a North American (U. S., Canada, Mexico) Affiliate Member. My check for $95 is enclosed.

_____Yes, I would like to join as a non-North American Affiliate Member. My check for $150 is enclosed.

_____Other people in my company would also like to join as Affiliate Members of PCI at $95 ($150 for non-North American members) each.

Please enroll the following additional individuals as Affiliate Members:

______________________________________________________________________

Please print or type

Company Name:__________________________________________________

Name:__________________________________________________________

Street Address:___________________________________________________

City, State, Zip:___________________________________________________

Country:________________________________________________________

Phone:(___)_______________________ FAX:(___)_____________________

Payment Method:

___ Check (payable to The Powder Coating Institute or PCI and drawn on a US bank)

___ VISA    ___ Mastercard    ___ American Express

Card #:___________________________________ Exp. Date: ____________________

Name:_________________________________________________________________

Signature:_______________________________________ Date:___________________