MEMBERSHIP REVISION FORM
Complete and send this form to:
Jason Blake, General Counsel, ReliabilityFirst Corporation
3 Summit Park Drive, Suite 600 • Cleveland, OH 44131
Fax: 216-503-9207
Email: [email protected]
Please provide revised information. Enter N/C if there is No Change.
1. Current Member Company Information:
A. Member Company's Full Legal Name:
B. Main Office Address:
C. Main Office Telephone Number:
D. Member’s Sector Designation:
E. Member's geographical area of operation:
(Indicate States or Provinces)
F. Membership Class (Regular, Associate, Adjunct):
2. Updated Member Company Information:
A. Member Company's Full Legal Name:
B. Main Office Address:
C. Main Office Telephone Number:
D. Member’s Sector Designation:
E. Member's geographical area of operation:
(Indicate States or Provinces)
F. Membership Class (Regular, Associate, Adjunct):
3. Affiliates of Member Company:
Current names of any and all Affiliates that are eligible to join, or have joined, an Industry Sector:
Please provide the Revised/Additional names of any and all Affiliates that are eligible to join, or have
joined, an Industry Sector:
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4.
Related Parties of Member Company:
Current names of any and all Related Parties that are eligible to join, or have joined, an Industry Sector:
Please provide the Revised/Additional names of any and all Related Parties that are eligible to join, or
have joined, an Industry Sector:
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5. Persons authorized to act on behalf of Member Company:
Current information for those persons authorized to act on behalf of Member Company with respect to all
ReliabilityFirst matters:
Primary Representative
Name:
(1)
Title:
(2)
Address:
(3)
Telephone:
(4)
Fax:
(5)
Email:
Alternate Representative
Name:
(1)
Title:
(2)
Address:
(3)
Telephone:
(4)
Fax:
(5)
Email:
Please provide below revised complete information for those persons who will be authorized to act on
behalf of Member with respect to all ReliabilityFirst matters:
Primary Representative
Name:
(1)
Title:
(2)
Address:
(3)
Telephone:
(4)
Fax:
(5)
Email:
Alternate Representative
Name:
(1)
Title:
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(2)
Address:
(3)
Telephone:
(4)
Fax:
(5)
Email:
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The original application was signed by the following:
ORGANIZATION:
Company:
Name:
Title:
Date:
The undersigned certifies that the above information is accurate and complete.
ORGANIZATION:
Company:
Signature:
Name:
Title:
Date:
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