WE CAN HELP GROW YOUR BUSINESS
                 HCIBA MEMBERSHIP APPLICATION

Membership dues in the Harrison County Independent Business Alliance may be tax deductible as an ordinary
and necessary business expense. Dues paid to the HCIBA are not a charitable tax deduction for income tax purposes.
The HCIBA is a 501C-6 and is not a charity, but serves as a powerful organizing force for local businesses.
(see IRS reg 11.162-6) Our national chapter, AMIBA, is structured as a 501 C-3.

Date___________,  Contact Person__________________, Title__________

Firm Name_____________________, Owner_________________________

Category of Business____________________________________________

Product or Service______________________________________________

Address_______________________________________________________

City, State, ZIP_________________________________________________

Bus. Phone___________, Cell#___________, Fax #___________, Hm____________

E-mail Address_______________________, Web Address______________________

Number of Employees: Full-Time________, Part-Time________

Why are you joining?_______________________________________________________________

________________________________________________________________________________________________

(check one)Basic $25____, Business $50___, Corporate $100-$5000____

I pledge to be actively involved, attend at least one meeting per quarter,  and actively help to expand HCIBA membership

in the best interest of my county / employees / fellow businessmen. Approved for HCIBA by_______________________

Signature________________________, Amount Paid $___________
HCIBA, 2690 Breckenridge Road NE, Corydon, IN  47112   812-952-3580  Meetings: 2nd Wed each month 6PM
www.amiba.net / www.hciba.net  Founding members: Andrew Best, Steve Boehman-President (812-952-3580), Debra Partin-Past President, Gordon Pendleton, Jim Heitkemper, Larry Miles, Ms Kerry DeMuth,
John Beams, Roger Gleitz, David Kocka, Ike Orwick, Greg Albers, Jerry Dryden, Mark Bush, Steve Tucker,
Larry Ott, Jim Thieneman, Tom Marlatt, Gordon Ingle, & Darrell Rainbolt.
e-mail: hciba1@yahoo.com