Please Print this Form, Complete and Mail to:

MTA

P.O. Box 851

Helena, MT 59624

BUSINESS NAME:
MAILING ADDRESS:
STREET ADDRESS (if different from above):
CITY:	STATE:	ZIP:
NAME OF LICENSEE:
NAME OF MGR:
MT RETAIL LIC .#:	FED ID#:

REGULAR MEMBERSHIP (Licensees Only)
Base Dues	$ 100.00
PLUS - No. of Keno & Poker Machines X $15.00 each	$
Optional Gold Star (Show of support for MTA – Additional $100.00)	$
TOTAL	$

ASSOCIATE MEMBERSHIP (Non-Licensees Only)
Type of Business:
Individual Firms $100 (Optional Gold Star – Additional $100)	$
Minor Distributor $250 (Optional Gold Star – Additional $250)	$
Major Distributor $500 (Optional Gold Star – Additional $500)	$

Complete the following payment information:
____Check enclosed for	$_____________
____Credit card charge* for *Plus 3% Convenience Fee	$_____________
___MasterCard ___Visa ___American Express
Credit Card # ____________________		Exp. Date __________		CID/Card Code _____
Signature: _______________________________			Phone#: __________________
Cardholders Name (Please Print): _________________________________________
Address: _____________________________________________________
City: ___________________________________			State: _______		ZIP: _________

DUES CANNOT BE PRORATED.  Schedule adopted by 1990 Convention. Dues include $20.00 annual membership in the American Beverage Licensees (ABL).

NEW MEMBERS: If dues are paid in May, you will receive two (2) free months of membership (May & June) and dues will be paid through June 30^th of next year.

IRS code Sec.162(e) disallows deductions for expense of lobbying. The portion of MTA dues expended for this purpose is 15% & ABL is 5%. INFORM YOUR ACCOUNTANT !!!!