This document is an application for membership in the American Independent Business Coalition (AIBC). It collects information such as the applicant's name, address, dependents, contact details, and preferred payment method and schedule for membership dues. The applicant agrees to timely payment of dues at the selected membership level, and that dues amounts may change with proper notice. Payment will be made either via monthly bank draft or direct billing, and the application can be terminated by either party with 30 days notice.

1. AIBC-APP-GROUP
1. Full Name of Applicant and Each Dependent Effective Date:
(Last) (First) (Middle) Member SSN Sex Date of Birth
SPOUSE
CHILD
CHILD
CHILD
CHILD
CHILD
Mailing Address: Apt. #:
City: State: Zip:
Home Phone: ( )
I would like to pay my Membership Dues Monthly Quarterly Semi Annually Annually
I would like to pay my initial payment by Bank Draft (provide account information on back) Direct Bill
Credit Card Type: VISA MASTERCARD AMERICAN EXPRESS DISCOVER
Account # Expiration Date:
Please provide the name on the card:
First: Middle: Last:
Provide Billing Address:
Signature of Cardholder:
AIBC Membership Level: Pearl $22.95 Ruby $32.95 Sapphire $42.95
Emerald $52.95 Diamond $62.95 Executive Diamond $89.95
Select your Membership Level
(continued on back)
American Independent Business Coalition. The undersigned Primary Member Enrollment Applicant, individually and on behalf of all Applicant(s) listed above,
hereby:
1. makes and tenders this Primary Member EnrollmentApplication for membership in the association;
2. represents that the other individualApplicant(s) listed above are the legal spouse and/or children as designated, and that any such children are either under
the age of 19 or a full-time student between the ages of 19 and 24;
3. understands and agrees that in order to maintain membership in the association, the timely payment of Membership Dues is required during each calendar
month;
4. understandsandagreesthatsuchMembershipDuesareintheamountoftheMembershiplevelselected,percalendarmonthandthatthecalendarmonthly
amount of such Membership Dues may be changed in the future at the discretion of the managers of the association, but not without prior written notice
Primary Member Enrollment Application
I hereby make application to enroll in the American Independent Business Coalition, by paying the initial $40.00 Membership Enrollment Initiation Fee and the
MembershipDuesfortheMembershiplevelselected.IunderstandthatafteracceptanceofthisPrimaryMemberEnrollmentApplicationandreceiptofmyMembership
hisorherlegalspouseandtheirchildren,ifnamedinthisPrimaryMemberEnrollmentApplication,undertheageof19years(24ifenrolledasafull-timestudent).Ialso
AIBC-GRP-0115

2. AIBC-APP-GROUP www.aibcoalition.com
Signature of Primary Member Enrollment Applicant: Date:
AIBC Representative: Representative # Date:
Bank Name: Jane Doe 1234
2139 S. 33 St. Date:_______
Anytown, USA 12345
_________________________________________________ $
_______________________________________________________ Dollars
Bank Name
Memo_________________ _____________________
(Routing #) (Account #) (Check #)
Address:
City:
State:
Zip:
Routing # (9 Digits) Account #: Next Check#:
5.
more third parties, and in such event, understands and agrees that the designated third party is solely responsible for provision and/or administration of such
6. understands and agrees that any future change in the Membership Dues will only occur if such Membership Dues are changed for all members of the
association in my/our class of membership;
7. understands and agrees that the initial Membership Dues in the amount of the Membership level selected have been collected from me today along with this
8. understands and agrees that a one time Membership Enrollment Initiation Fee in the amount of $40.00 has been collected from me today along with this
Primary Member EnrollmentApplication for transmittal to the association;
9. understands and agrees that membership in the association shall be effective as of the date the Primary Member EnrollmentApplication and the enclosed
payment of the Membership Enrollment Initiation Fee and the initial Membership Dues are received by the association.An enrollment application received
on the 29th, 30th, or 31st of the month, will be assigned a membership effective date of the 1st of the following month;
10.
11. understands and agrees that payment of future Membership Dues will be either by regular monthly bank draft from my checking account or regular direct
monthly billing with payment by return check, as indicated;
12. authorizes and directs the association, or its approved and authorized designee, to bill and collect future Membership Dues in accordance with the method
and schedule of payment selected. If monthly bank draft has been selected as the method and schedule of future Membership Dues then the association,
or its approved and authorized designee, is directed to commence drafting my checking account for the amount of such Membership Dues starting the next
month after my membership in the association becomes effective and continuing for each month thereafter;
13. understands and agrees that if monthly bank draft has been selected as the method and schedule of payment of future Membership Dues, he/she hereby
requests, authorizes, and instructs the association, or its approved and authorized designee, to initiate debits from my checking account listed, provided
neither the association nor its approved and authorized designee will send me any payment notice while this authorization is in effect. The association, or
its approved and authorized designee, may revoke payment under this method and schedule acceptable to the association in order to keep the coverage
paid current. I understand that the authority of the association, or its approved and authorized designee, to draft my bank and checking account shall remain
in effect until I notify, and the association, or its approved and authorized designee, receives my request for an alternative payment method and schedule
reason,thentheassociation, or its approved and authorized designee, maychangethemethodofpaymentofsuchfutureMembershipDuestodirectbilling
in which event required payments must be timely made by check;
14. understands and agrees, regardless of the method or schedule of Membership Dues payment selected, if the Membership Dues are not timely and
available;
15.
days prior to the next regularly scheduled payment of the Membership Dues.
then the Primary Member EnrollmentApplicant shall make written request to the association for such supplemental enrollment. However, no such supplemental
enrollmentwillbeeffectiveuntilacknowledgedinwritingbytheassociation.InsigningthisPrimaryMemberEnrollmentApplication,theundersignedacknowledges
that he/she has read and understands all information contained in paragraphs 1-16 above and that all statements of the Primary Member Enrollment Applicant
contained herein are true and correct.
I agree to comply with the By-Laws of the association during my membership enrollment and during the term of my membership in the association.
James Matlock Y9Y1A130