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Please fill out and print this form and either mail or FAX to:

Minnesota Licensed Beverage Association
St. Paul Business Center East
1983 Sloan Place • Suite 6
St. Paul, MN 55117
FAX: 651-772-0900

Application is hereby made for membership in the Minnesota Licensed Beverage Association. The financial investment is as follows:

Restaurants, Taverns, Clubs, Etc. (Check your category)

Automatic Dues/Month

Dues/Year

$24.91

$299.00

Package Liquor Stores

Automatic Dues/Month

Dues/Year

$24.91

$299.00

 

ALL ADDITIONAL UNITS ARE $170 EACH - PLEASE ATTACH LIST
(Please Print or Type Application)

$ For unit(s)


Business Name:

Corporate Name:

Address:

City:

State:

Zip:

Phone:

Fax:

Signature:


Primary Business:


Please Select One:

Visa; - M/C; - Discover;
Check Enclosed

Name on Card:

Address/Zip on Card
Card Number:

3 - Digit Sec. Code :

Expiration Date:


AUTHORIZATION FOR AUTOMATIC PAYMENTS

I authorize the Minnesota Licensed Beverage Association, Inc. and the bank named below to initiate variable entries to my checking/savings account. This authority will remain in effect until I notify you or the bank in writing to cancel it in such time as to afford the bank a reasonable opportunity to act on it. I can stop payment of any entry by notifying you or my bank 3 days before my account is charged. I can have the amount of an erroneous charge immediately credited to my account up to 15 days following issuance of my bank statement or 48 days after posting, whichever occurs first [Complete the following or sign it and attach a voided check]:


Name of Financial Institution:

Address of Fin. Inst:

City of Fin. Inst:

State of Fin. Inst:

Zip Code of Fin. Inst:

Your Name:

Your Address:

City:

State:

Zip Code:

Checking Account Number:

or

 

Savings Account Number:

Bank Routing Number:

Signature:


Your financial investment in the Minnesota Licensed Beverage Association is neither a gift nor a contribution. It is a tax deductible business expense and must accompany this application. Your membership investment is subject to review by the Association's Membership Committee and to final approval by the Association's Board of Directors.


Proposed By:

Date: