2007 IBWA International Membership

Dues Form

 International Bottler International Supplier International Distributor

International Bottler

IBWA International Bottler members are companies located outside the United States that bottle or package water for sale outside the United States and that meet IBWA Code of Practice standards which is verified by annual plant inspections.

This inspection is MANDATORY.

All new and renewing International Bottler members must provide IBWA with a current certificate of inspection from an IBWA-approved, third-party organization, which shows a passing score. Please send this along with your dues payments to ensure complete processing of your membership application or renewal.The third-party organizations currently approved by IBWA are:

NSF International / QUASI
Contact: Adam Bloom / Contact Robert Gelbach
789 Dixboro Road / 6555 Wilson Mills Road Suite 102
Ann Arbor, MI 48105 USA / Cleveland, OH 44143 USA
Telephone: 734-827-3828 / Telephone: 440-442-0336, ext. 247
Fax: 734-827-7121 / Fax: 440-442-0341
Internet: / Internet:

You may contact one of these organizations to arrange an inspection. You are responsible for the fees associated with the annual inspections.

International Supplier

IBWA International Supplier members are companies located outside the United States that are engaged in the rental or sale of equipment, products, supplies or services to the bottled water industry and only have sales outside the United States.

International Distributor

IBWA International Distributor members are companies located outside the United States that do not produce or bottle water and that distribute for IBWA Bottler members located outside the United States.

Renewing Members

Membership dues become payable January 1, 2007. To guarantee uninterrupted membership services, dues payment must be received at IBWA headquarters no later than February 5, 2007.

EARLY BIRD DISCOUNT: Renewing member companies that pay dues, in full, by the deadline date of February 5, 2007, may deduct $100.00 from their dues payment.

I. Contact Information

Company Name

Address

City/State/Zip

Country Postal Code

Telephone Fax

Website

(The IBWA web site lists all member company web sites and provides a hyperlink to those sites)

Primary Representative Title

(Primary contact person to receive all communications from IBWA, including renewal invoices and industry alerts)

Telephone Fax

2007 IBWA International Membership

Dues Form

Email

Alternate Representative Title

(Additional company employee to receive communications from IBWA as part of the membership)

Telephone Fax

Email

(Company information and information about gross sales will be used by IBWA only, in the aggregate with information from other IBWA members, when advocating for the bottled water industry with legislators and regulators)

II. Company Information

Number of Employees

Fluoridated water sales?  Yes No

Please indicate if your bottling plant is fully operational:  Yes No

Bottler Members Only

Product(s) and/or Service(s) – Supplier Members Only

Attach a separate sheet if necessary

My 2006 Gross Sales were: $

III.Payment Information

  1. Annual Dues
/ $1575.00
  1. Full Payment remitted by 02/06/2007
(ONLY Renewing IBWA Members) / -$ 100.00
  1. Voluntary Contribution to the Drinking Water Research Foundation (DWRF)
/ $
  1. Total amount enclosed
(If paying by check, make check payable to IBWA;U.S. funds only) / $

Circle one:Check enclosed

Or

Charge MasterCard Visa American Express Discover

(only cards listed are accepted for payment)

$______

Amount to be charged

______

Card Number Expiration date

______

Cardholder’s Signature

______

Cardholder’s Name (please print)

1700 Diagonal Road, Suite 650, Alexandria, VA 22314  TEL (703) 683-5213  FAX (703) 683-4074 

2007 IBWA International Membership

Dues Form

IMPORTANT – INTERNATIONAL BOTTLER MEMBERS

I have enclosed a current certificate of inspection from NSF International or QUASI

(Your membership application will not be processed without this information)

Payment of the above membership dues indicates agreement to abide by the IBWA Bylaws and other rules of membership in IBWA. See the enclosedConditions of Membership for Bottler Members and the Logo Use Policy for further conditions of IBWA International Bottler, Supplier and Distributor Membership. All sales and other information provided will be kept in the strictest confidence.

Signature Date

General Information

  • Dues paid to IBWA are deductible as an ordinary business expense but NOT deductible as “charitable” contributions for Federal Income Tax purposes. The portion of dues payments used for lobbying expenses by the association is not deductible for Federal Income Tax purposes. The nondeductible portion of your 2006 dues is 3.5%. Contributions to the Drinking Water Research Foundation (DWRF) are deductible as charitable donations for Federal Income Tax purposes. IBWA tax ID #25-1124210
  • $25 of your dues investment is applied towards your yearly subscription to the Bottled Water Reporter

Logo Use Policy

I hereby voluntarily acknowledge, agree and consent to comply with the guidelines for use of the IBWA logo and associated statements as set forth in the current IBWA logo policy (copy included) and to the following release as executed by signature herein:

“I, for good and valuable consideration, including the license to use the International Bottled Water Association (IBWA) logo and associated statements, hereby release and agree to indemnify and hold harmless IBWA from all claims, causes of action, liabilities or obligations of any kind, arising out of, connected with, or predicated upon membership in IBWA or the use of the said logo and associated statements, it being thoroughly understood that the use of the logo and statements shall never be construed to create warranty, express or implied, for or on behalf of IBWA in any manner whatsoever. I further agree that any goodwill derived from the use of the mark inures exclusively to the benefit of IBWA and I agree to carry and maintain at my own expense, all necessary product liability insurance adequate to protect IBWA and any third party.”

Fax this membership dues form with credit card information to

IBWA at 703-683-4074, or mail with credit card information or check payment to:

Membership Department

IBWA

1700 Diagonal Road Suite 650

Alexandria, VA 22314

For questions about IBWA membership, contact the IBWA Membership Department

at 703-683-5213, ext. 115 or

1700 Diagonal Road, Suite 650, Alexandria, VA 22314  TEL (703) 683-5213  FAX (703) 683-4074 

NOTE: Membership dues are payable on January 1 of each year

1700 Diagonal Road, Suite 650, Alexandria, VA 22314  TEL (703) 683-5213  FAX (703) 683-4074 