Application for Membership for NCCI
 
I hereby make application for membership in NCCI The Coal Institute, Inc., in accordance with the By Laws and by personal endorsement of the two member companies listed below.
Note: If you have no changes to your existing information, simply click here and skip to the "Billing Information" section of this form.
Applicant Information:
Company
Name
Title
Address
City
State
Zip
Email
 
Type of Company
Producing Sales Carrier Consumer Other
 
Names/Titles of company officers

1.
2.
3.
4.
*5.
*6.
 
You must have two people from member companies endorse you. Include their name and company information here.
1.
2.
* MEMBERSHIP DUES Annual Dues are $300.00/Company for a one person listing in the Membership Directory, $400/Company for a two-four person listing in the Membership Directory, and $600.00/Company for a five or more person listing in the Membership Directory per fiscal year (October 1 through September 30).
I intend to pay by: credit card check
 
Billing Information:
     
Name On Card:   Select Credit Card Type:
Billing Address For Card:   Card Number:
Street 1:
  Expiration Date: month/year
Street 2:    
City:      
State:      
Zip Code:      
Country:      
 
Renewal Information:
Enter the name and address of the person who should receive the Membership Renewal Notice.
Name:      
Mailing Address:
     
Telephone:
     
Fax:
     
Website:
     
 
Individual Information:
Please provide information for the individuals to be listed under the above address.
  Name Title Telephone Fax Email
1.
2.
3.
4.
5.
6.
 
Other Office:
Mailing Address:
     
Office Type:
     
Telephone:
     
Fax:
     
 
(Other Office) Individual Information:
Please provide information for the individuals to be listed under the other office address.
  Name Title Telephone Fax Email
1.
2.
3.
4.
5.
6.
 
 
To register by mail or courier, send your check made payable to
NCCI - The Coal Institute to :
 
U.S. Postal Service:
Ms. Karen Smith
P.O. Box 3672
Pikeville, KY 41502
For Fed-Ex or UPS Shipments:
284 Weddington Branch Road
Pikeville, KY 41501