Membership Application Form

Instructions:

To join, please follow these steps:

Complete the form on this page in full.

After submitting the form, click the provided link to pay your $150.00 membership fee through Eventbrite.

Important: Applications and payment will only be accepted once your application has been reviewed. You will be notified once the review process is complete.

Company Name

Date

Owner Name

Address 1

Address 2

City

State

Zip Code

Verify Your Region Here And Then Select Your Zone

Region (Check ONE)

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Out of State

Contact Information

Phone Number

Fax Number

Email Address

Website

Public Contact Information

Public Contact Email

PUBLIC CONTACT PHONE

Industry Guild Contact Person

Industry Contact Person Email

Industry Contact Person Phone

State Contractor License Number

Company Information

Services Offered

I have read and agree to the PA Guild of Professional Chimney Sweep Code of Ethics .

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