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Organization ___________________________

Phone __________________ Fax __________________

Address _______________________________

City__________ State _____ Zip_________

Authorized Official _______________________________

Title ________________ Alt phone# _________________

Email _______________

Other Representative _____________________________

Alt phone# ___________________

Email _______________________

Other Representative _____________________________

Alt phone# ___________________

Email _______________________

Membership with The Surplus Exchange is designated for Non-profit

Organizations which are exempt from Federal Income Tax. Current proof

of Non-profit status must be on file at all times with The Surplus

Exchange.

Lifetime membership with The Surplus Exchange is Fifty Dollars per

organization, payable with this application. Although we will not

require additional fees to maintain your membership, we do ask for

occasional updated documentation of yoiur Nonprofit status.

In order to serve your organization best, we also ask that you send

us a brief summary, or Mission Statement, describing your organization.

I, the undersigned, have read and understand the abouve, and affirm

that my organization meets the membership criteria.

Signiture_____________________________Date______________