Associate CMD Application

Certified Master Dealer® Associate Application**

**Certificate of Participation Only
( See Eligibility Criteria )


* Please indicate the class that you would like to attend:
November 20-23 , 2008

First Name,
MI, Last Name:

________________________________________________________________

Title / Position:

________________________________________________________________

Company Name:

________________________________________________________________

Mailing Address:

________________________________________________________________

City, State, Zip:

________________________________________________________________

Phone, Fax:

________________________________________________________________

Email, Website:

________________________________________________________________

Dealer License #:

________________________________________________________________

NIADA Membership #:

________________________________________________________________

Dealer's Approval Signature ___________________________________________________________


There is a $125 non-refundable application fee that must accompany the application. This application fee is non-refundable regardless of approval.

METHOD OF PAYMENT: Enclosed is a check made payable to NIADA
Visa MasterCard American Express Discover
___________________________________________ Cardholder's Name ___________________________________________ Card Number	___________________________________________ Expiration Date ___________________________________________ Cardholder's Signature

For Office Use Only
Date Received	Approved

Please complete is application and submit to:

Georgia Brown, Director of Education
NIADA
2521 Brown Blvd.
Arlington, TX 76006
Fax: 817-649-5866