Our company hereby applies for membership in the following category:

_______ Regular Membership (Companies actively engaged in thermographic printing).

_______ Affiliate Membership (Companies actively engaged in thermographic printing as a division, subsidiary or franchisee of a Regular Member).

_______ Associate Membership (Companies that are suppliers to a Regular or Affiliate Member).

Company: ____________________________________________________________

Address: ____________________________________________________________

City, State, Postal Code: ________________________________________________

Country: ____________________________________________________________

Telephone: ___________________________ Fax: ____________________________

Website: ____________________________ E-mail: ________________________

Primary Representative: ___________________________ Title:________________

Additional Reps: _________________________________ Title:________________

_________________________________ Title:________________

____ Enclosed is my check payable to the WPT.

FOR REGULAR AND AFFILIATE MEMBERSHIP

Total Number of Thermography Units: ________

_____ Number of 12" _____ Number of 20" _____ Number of 30"

_____ Other Size

Geographical Market Served

_____ G1 Local

_____ G2 Regional

_____ G3 National

_____ G4 International

Sheet Size

_____ S1 - 11x17 _____ S3 - 17x22 _____ S5 - 28x40

_____ S2 - 12x18 _____ S4 - 23x30 _____ S6 - Other (specify) ____

FOR ASSOCIATE MEMBERSHIP

Please indicate below the services/products your company
provides to the industry:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________