Application for Membership for The Coal Institute
 
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.
Renewal - 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:      
 
New Application or Renewal Change 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 company main listing.
  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.