| 1932 Industrial Drive |
| Libertyville, IL 60048 |
| (847) 367-6650 x 155 |
Please print this page, complete the information below and enclose a check or money order made payable to NISA for $65.00 USD, Foreign $85.00 USD, and mail to the above address.
| Name: | _________________________ | Date: | ______________________ | |||
| Company: | _________________________ | Telephone: | ______________________ | |||
| Address: | _________________________ | Fax: | ______________________ | |||
| _________________________ | ______________________ | |||||
| _________________________ | ||||||
| BUSINESS CATEGORY | TYPE OF INTEREST | |||||
| ________ | Scale User | ________ | Belt Scales | |||
| ________ | Scale Manufacturer | ________ | Rail Scales | |||
| ________ | Railroad | ________ | Truck Scales | |||
| ________ | Regulatory | ________ | Hopper Scales | |||
| ________ | Dealer/Representative | ________ | Automatic Equipment Identification | |||
| ________ | Other | ________ | Electronic Data Interchange | |||
| _________________________ | ________ | Other | ||||
| _________________________ | ________________________ | |||||
| _________________________ | ________________________ | |||||