Midwest Furniture Club Membership Application

Member Type

Membership Type*

Payment Type

Payment Method*

Payment instructions will be sent in the sent in your confirmation email.

Name*

First Last

Spouse Name

First Last

Company Name (If applicable)

Website

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone

Cell Phone

Fax

Email*

Referred by?

First Last

Territories

List all of the territories you cover. Use 2 letter state abbreviations and separate with a comma.

Lines / Product Types Represented:

(Please include the product line carried ‒ i.e. upholstery, case-goods, etc.)

Are you looking for Lines?

Product Type

Website