2009 Retail Associate Membership Application
(Convenience Stores, Liquor Store, Gas Station, Grocery Store, Other Retailer)

Company: ________________________________________________________________

Address: __________________________________________________________________

City/State: ___________________________________________________ Zip  __________

Telephone: ________________________________________________________________

Facsimile: _________________________________________________________________

E-Mail: ____________________________________________________________________

Key Contact: _______________________________________________________________

Membership Dues - Annual Rates (Check One)

1 Store                         $   100.00	6 Stores                       $  375.00
2 Stores                       $   175.00	7 Stores                       $  400.00
3 Stores                       $   250.00	8 Stores                       $  425.00
4 Stores                       $   300.00	9 Stores                       $  450.00
5 Stores                       $   350.00	10 Stores                       $  475.00
11 or More Stores: Dues for First 10 Stores:     $ 475.00   Plus: $15.00 For Each Store Over 10 Stores:     $_______   Total 2008 Retail Associate Membership Dues     $_______

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

 Check Enclosed          VISA           MasterCard          Discover      American Express

Card Number:  _______________________________________  Exp. Date:  _____________

Signature:        ________________________________________________________________

NOTE: If you own more than one store, please return a store list with your application since all store locations will be matched to state and Congressional legislative districts.  

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