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Application
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Membership Type
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Associate Membership
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TN
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VT
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MB
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NU
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CM
CP
DF
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JA
MC
MR
MX
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Additional Information
Briefly Describe your Product or Service
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Principal Grocery Supplier
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Type Of Operation (Check all that apply)
Supermarket
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Other
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Type Of Ownership (Check all that apply)
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Total Annual Sales Volume of Pennsylvania Stores
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Is This A Multi Unit Operation?
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Total Number of Units in All States
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Total Full Time Employees
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Do Any Of Your Stores
Accept Coupons
Perform Compliance Checks
Participate in a Scholarship Program
Do you have a relationship with any legislator that may assist the food industry in Pennsylvania? If yes, which legislator(s) and what relationship? (i.e. Governor, Friend)
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Membership Investment
Primary Directory Category
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Accounting
Advertising/Printing
Associate Member
Associations
Bakery
Beverages/Coffee
Business Services
Catering
Center Store
Cleaning Products
Coffee
Confectionery
Construction Services
Construction/Engineering
Consulting, Analytics & Technology
Convenience Store
Convenience Store Solutions
Coupon Processing
Dairy
Deli/Meats
Delicatessen
Education
Eggs/Poultry
Energy and Equipment
Energy Consulting
Engineering & LEED/Sustainable Design
Environmental
Environmental Services/Remediation
Equipment
Financial Services
Flooring
Food Manufacturer
Forestry
Frozen Foods
Gaming
General Merchandise
Insurance
Legal Services
Loss Prevention
Lottery
Money Services
Other
Packaging, Plastic Bag and Film Products
Partner
Pet Food
Pharmacy
Produce
Sales & Marketing
Site Selection
Snack Foods
Software / Systems Management
Store Design and Construction
Superette
Supermarket
Telecom
Tobacco Products
Training
Transportation
Underground Storage Tanks
Utilities
Water
Wholesalers
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none
Amount Sales (no commas or spaces)
Annual Membership Investment
Total
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Number of Rooms
Number of Seats
Number of Associates
Number of Locations
Additional Items
Additional Categories Cost
One-Time Application Fee
Tax
Full-Time Employees
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Part-Time Employees
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Hotel/Motel Rooms
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Restaurant Seats
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Additional Associates
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Additional Associates Cost
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Additional Locations
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Additional Locations Cost
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Assets
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Assets Cost
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Additional Categories
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Number Of Additional Categories
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Additional Categories Cost
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Additional Item 1 Cost
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Additional Item 2 Cost
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Additional Item 3 Cost
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Additional Item 4 Cost
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Additional Item 6 Cost
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Additional Item 7 Cost
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Additional Item 8 Cost
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Additional Item 9 Cost
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Additional Item 10 Cost
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Annual Dues (charged to card)
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Revenue Item
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Tax (charged to card)
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Fee (charged to card)
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Temp Value For DropDown 1
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Membership Type
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Additional Item 1
Additional Item 2
Additional Item 3
Additional Item 4
Additional Item 5
Additional Item 6
Additional Item 7
Additional Item 8
Additional Item 9
Additional Item 10
Payment Type
Credit Card
Check
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.
Credit Card Information
Copy from Organization Information
Credit Card Type
Mastercard
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Credit Card Number
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Name on Card
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Security Code
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Valid Through
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2025
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2031
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2034
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2036
2037
Credit Card Billing Address
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Credit Card Billing City
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Credit Card Billing State
AK
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AZ
CA
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DE
FL
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HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
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Credit Card Billing Zip
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Phone
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Credit Card Email Address
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