Member

Thank you for your interest in becoming a member of the National Independent Concessionaires Association! Please take your time filling out the following information, as it will be used for our annual membership directory and your online member listing. If you have any questions about applying, our organization, or our featured benefits, please call the NICA Office at (813) 438-8926.

Business Information

Company Name: *

Leave Blank:

Phone: *

Website:

Email: *

Business Description (350 char max): *

Directory Category: *

Comments / Questions:

Referral:

Are you an Independent Concessionaire?: *

Route - List all states / provinces where you conduct your concession business (e.g. FL, NY, CA, etc.):

Accidental Death & Dismemberment (AD&D) Beneficiary:

Would you like to sign up for Auto-Renewal?: *

Would you like to sign up for paperless billing?: *

List three Fairs, Festivals, or Events you intend to work or have worked in the past year:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Social Networking:

LinkedIn Facebook Twitter

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook Twitter

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Cell Phone:

Fax:

Email: *

Contact Preference:

Email Phone

Password: *

Social Networking:

LinkedIn Facebook Twitter

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Print Application

Member Application

Mailing Address

Address

Address