MCTA Application

Massachusetts Chemical & Technology Alliance Application

Company Name:

Representative Name:

Email Address:

Title:

Name of Alternates:

Email Address:

Address:

Street:

City:

State:

Zip:

Phone:

Fax:

Applicant is applying for membership as(please check one):

Individual

Partnership

Corporation

Joint Venture

If applicant is a partnership, state the name of each partner:

If applicant is a corporation or division or other unit thereof , state the name and address:

	Name:	Street:
		City:
		State:
		Zip:

If applicant is a joint venture, state name of each participant in the joint venture:

Name:			Name:
State of Incorporation:			State of Incorporation:
Street:			Street:
City:			City:
State:			State:
Zip:			Zip:

1. What is the relationship between your business and those companies involved in manufacturing, distributing and using chemical products?

2. Location(s) of plants/facilities in Massachusetts:

3. Nature of applicant's US business:

4. Nature of applicant's Massachusetts business, if different than #3 above:

5. Do you accept and support the Mission Statement of MCTA?

Information provided in Questions 8 and 9 is optional and will be used by the MCTA office only for aggregate assessment of the economic and employment impact of MCTA member companies.

6. Number of applicant's employees working in Massachusetts:

7. Applicant's consolidated U.S. net sales: