Company:   ________________________________________________________________

Address:  __________________________________________________________________  

City/State: ___________________________________________________ Zip  __________

Telephone: ________________________________________________________________

Facsimile: _________________________________________________________________

E-Mail: ____________________________________________________________________

Key Contact: _______________________________________________________________

Membership Dues - Annual Rates (Check One)
Annual Sales Volume		Annual Dues
	$0 to $10 million	$ 1,150.00
	$10 million to $25 million	$ 2,300.00
	$25 million to $50 million	$ 3,500.00
	$50 million to $100 million	$ 4,500.00
	$100 million to $5 billion	$ 7,500.00
	$5 billion to $10 billion	$ 9,000.00
	$10 billion+	$ 14,000.00

Mail this form with check payable to “NATO” or fax with credit card information to:

National Association of Tobacco Outlets 15560 Boulder Pointe Road Minneapolis , MN   55347 Fax:  952-934-7442

Credit Card:          VISA           MasterCard          Discover      American Express

Card Number:  _______________________________________  Exp. Date:  _____________

Signature:        ________________________________________________________________

Note: Pursuant to federal law, NATO is required to advise you that 30% of your annual membership dues are not tax deductible.