2501 North Front Street, Harrisburg, PA 17110-1189

Ph: 717/234-3255    Fax: 717/234-3316

Name of Company:

 

PO Box:

 
City:  State:  Zip:

Physical Address:

 
City:  State:  Zip:

Telephone:

 

Fax:

 

Email Address:

 

Web Site URL:

 
   

No. of Employees:

 

Primary Contact:

 

Type of Business:

 

Name of Parent Co.:

 

Minority Contractor:

Yes No

Minority Type:

DBE MBE WBE

Labor Affiliation:

Union Non  Both N/A

COOL:

Yes No
   

Previous member of the Exchange?


 No  Yes

If Yes, when?

 
   

Our membership will include Entrance Fee, Annual Dues and Cool based on the current fee schedule.
View Fee Schedule

In order to complete the membership application, a valid e-mail address must be used as an invoice will be delivered to you immediately upon submitting this form.  Print the invoice, enclose a check or money order for the amount you've indicated, and mail to the address shown on the invoice.

Thank you for your support and welcome to the Mid Atlantic BX!

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