___ One-year $299. ___Three-Years $897. (Mandatory with 3-year Bond)

Date__________________________        Renewal_____  New Membership_____ Member Number: ___________

___Renewal          ___New Member  

 Company Name:                                                                                                             

 

Proprietor:                                                                                                                     

Business Address:                                                                                                         

City/State/Zip:                                                                                                                             

Mailing Address, if different:                                                                                

Phone:                                     Fax:                                         Cell:________      ___             

E-mail Address:                                                              Co. Website:                            

Check all that apply: Do you sell your cars:

Wholesale __________  Retail ____________     Internet____________

How many locations do you do business in?                    (List locations on back)

How many cars do you sell monthly?

How many cars are you licensed to have on your lot?

_____________________________________________________________________________         

MC/VS____________________________________Exp Date:                                     

Name as it appears on the Credit Card:                                                                 

Method of Payment:                                    Membership Expiration:                               

Referring Member: _______________________________________________________

Make check payable to MIADA and send to: 1408 Providence Hwy., Norwood, MA  02062

Referred by: (Internet)