Application

Company Information
Company Name :
Address :

City :
State :
Zip Code :
Telephone :
Fax # :
Company URL :	http://

Designated voting representative or proxy: (Please list an officer or partner)
Prefix :
First Name :
Middle Initial :
Last Name :
Position :
Phone :	Ext.
Fax # :
E-Mail Address :
Status :	Technical Representative (Check here if you will fill both posotions)

The following CSA members are known by me and have agreed to sponsor this application. (List at least 2 and include Member Name & Company)
Sponsor #1 :
Sponsor #2 :
Sponsor #3 :
Sponsor #4 :

In order to help us better understand the nature of the your business, please provide a general statement describing your company:

After becoming a member and to access the Member Section of this site, we will need to have a Username and Password for your organization:
Desired Username:	(6-12 alphanumeric characters)
Desired Password:	(6-12 alphanumeric characters)
Re-Type Password:
	If you loose your username or password, you can request it via email at a later date.

Disclaimer

By submitting this form, the afore mentioned voting representative, hereby makes application for membership in Chemical Sources Association, Inc., and agrees to subscribe to the Articles of Incorporation and Bylaws of that Association. Before completion of this application, a check covering the initiation fee of $200.00 and dues for one year in the amount of $325.00 (Total $525.00) will be mailed to CSA and processed.

The afore mentioned voting representative understands that membership is limited to companies that are manufacturers and/or disctributors of flavoring ingredients, flavors, extracts, aromas, or related raw materials who are engaged in the business of originating, developing or selling flavoring ingredients, flavors, extracts aromas or related raw materials.

03/15/07

Membership Application