Membership Application

2021 Membership Package

Organization Information (to be displayed online)

Company Name Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Contact #1 First Name Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Contact #1 Last Name Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Contact #1 Title Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Contact #2 First Name Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Contact #2 Last Name Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Contact #2 Title Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Mailing Address

Address 1 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Address 2 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

City Required Please enter a valid number Please enter a valid date Please enter valid credit card information

State

Zip Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Street Address

Address 1 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Address 2 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

City Required Please enter a valid number Please enter a valid date Please enter valid credit card information

State

Zip Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Contact

Company Phone Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Fax Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Website Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Email Addresses

Contact Person #1 Email Required Please enter a valid number Please enter a valid date Please enter valid credit card information Must be a valid email address

Contact Person #2 Email Address Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Information

Is your company covered by a provider for WC Insurance Coverage?

If yes, please list Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Would you be interested in receiving more information or a quote on your workers' compensation coverage from CompTrust AGC?

Does your company provide a 401k multi employer plan or retirement plan for employees?

State General Contractor's License Number Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Primary Construction or Business Type Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Other constructio types performeced (check all that apply)

Building
Highway
Heavy
Industrial
Municipal Utilities
Railroad
Foreign

MS State Board of Contractors Ceritificate of Responsibility

For New Associate Members

Please briefly describe the scope of your wor Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Membership Investment

Membership Type

Primary Directory Category

Annual Membership Investment

Total

Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

The contents of this box are for testing purposes. This box will be removed when the form goes live.

Full-Time Employees Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Part-Time Employees Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Hotel/Motel Rooms Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Restaurant Seats Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Associates Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Associates Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Locations Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Locations Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Assets Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Assets Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Categories Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Number Of Additional Categories Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Categories Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 1 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 2 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 3 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 4 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 5 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 6 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 7 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 8 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 9 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 10 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Annual Dues (charged to card) Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Revenue Item Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Tax (charged to card) Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Fee (charged to card) Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Temp Value For DropDown 1 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

MembershipType Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 2

Additional Item 3

Additional Item 4

Additional Item 5

Additional Item 6

Additional Item 7

Additional Item 8

Additional Item 9

Additional Item 10

Number of Full Time Employees

Number of Part Time Employees

Number of Rooms

Number of Seats

Number of Associates

Number of Locations

Millions in Assets

Enhanced Membership ($50)

Additional Items

Additional Categories Cost

One-Time Application Fee

Tax

Additional Directory Categories

Select additional directory categories below by holding the "CTRL" key
Secondary categories may be subject to additional fees

Credit Card Information

Credit Card Type

Mastercard

Visa

Amex

Credit Card Number Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Name on Card	Required
Security Code	Required
Valid Through
Address	Required
City	Required
State
Zip	Required
Phone	Required
Credit Card Email Address

By providing the information above, I am agreeing to receive communication sent by or on behalf of AGC of Mississippi and the Associated General Contractors of America via mail, telephone, fax, or email. If you have questions, please call Jessica Houdsan at AGC Mississippi [email protected] or 601-981-1144. Mail completed forms to AGC of Mississippi, Attn: Membership, PO BOX 12367, Jackson, MS 39236.

Please click submit only one time. The transaction may take several seconds.

Please select a membership type before submitting your application.

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