Independent Gas Station Owners Association

Tel : (937) 470-9400   /   Fax: (937) 435-5556   /   Email: info@igsoa.net   /   Website: www.igsoa.net

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Dealer Registration Form

To Join the Group Please - Fill it up and fax to : (937) 435-5556


Nature of Membership : ______ Dealer ________ Vendor  _______ Service Providers  -  (Check One)

Name of Business : ___________________________________________________________________________________________

Address : _____________________________________________________________________________________________________

Contact Name : ________________________________________  Email: _______________________________________________            

Tel: _____________________________Fax : _____________________ Email: _____________________________________________            

Referred by  : __________________________________________________________________________________________________           

Change of Address : ___________________________________________________________________________ (if applicable)

Tel: _____________________________Fax : _____________________ Email: ____________________________________________            

Signature:_________________________________________________________________________________________

(Print Name):______________________________________________________________________________________          

 

Approved By : _____________________________________________  Dated : ______________________________

(Print the Name) : _________________________________________________________________________________

Membership # : _________________________________________________ Dated : _________________________  

 

 

 

 

 
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Last modified: Tuesday February 03, 2015.