"The Premier 8(a) Association for Successful Government Contracting"

 
 

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MEMBERSHIP APPLICATION

( Printer Friendly Version )
Company Name:  ____________________________________
Address:  _________________________________________
City:  ________________
State:  _______________
Zip:  _________________
Phone:  _______________
Fax:  _________________
Email:  ________________________________
Web Address:  ________________________________
Point of Contact:  ________________________________
Primary NAICS:______________     2nd NAICS ______________      3rd NAICS ______________
# of Employees:  _____
Provide the description for your Products & Services as you would like to see listed in the membership directory:  _____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Type of business:
Alaskan Native ___   Native American ___   Minority ___   Woman-owned ___   Veteran Owned ___
Service Disabled Veteran Owned ___
ANC subsidiary ___   if so, name of ANC: _____________________________________________


Membership Classifications

(check the one that applies to your company)

Regular: current eligible 8(a) company (with voting rights)
Honorary: 8(a) company who has successfully graduated from the program (without voting rights)
Associate: other organizations who would like to join the association (without voting rights)



By submitting this application the applicant is self-certifying the following:


This certifies, to the best of the applicant's knowledge and belief, that the applicant company/principals are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency; and have not, within a three (3) year period preceding this application been convicted of or had a civil judgment rendered against them for:  commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a Federal/state government contract or subcontract; violation of Federal/state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property, and are not presently indicted for, or otherwise criminally or civilly charged by a Government entity with, commission of any of these offenses.

Annual Membership for each designated category above:  $800.00
($100/year for a non-profit or government agency)
Visa & MasterCard accepted

Non-transferable/non-refundable

"Each individual company requires a membership."

Mail application to:

PO Box 243802
Anchorage, AK.  99524

 


Do not write in this box.....for Office Use Only


Date received: ________________     Paid by:  check ___   credit card ___

New Member: ___     Former Member: ___     Renewal Member: _____

Anniversary month: ______________