Application for Membership

Name
First Last
Home Phone
Business Name
Business Mailing Address
Street Address City State ZIP Code
Is Your Business street address different than mailing address?*
- No
- Yes
Business Street (Physical) Address
Street Address City State ZIP Code
Type of Business:*
- Individual
- Partnership
- Corporation
First Year Business Operated
Approximate Number of Employees
Number of Full-Time Employees
Number of Part-Time Employees
Have you previously been a member of the Mahoning Valley Landscape and Nursery Association?*
- Yes
- No
What year(s) were you a member?
If you are a member of any of the following professional organizations, please check below
- Ohio Nursery and Landscape Association
- Ohio Landscape Association
- American Nusery and Landscape Association
- Ohio Lawn Care Association
Did an MVLNA member recommend you to join?*
- Yes
- No
Name of member
Phone of member
Business Information
Name of Your Business Liability Insurance Company
Insurance Company Phone Number
Federal ID Number
Workers' Compensation Risk Number

(For information go to www.ohiobwc.com)
State (OH or PA) Service Vendor's or Vendor's License Number

(To obtain a Service Vendor's License in Ohio, go to http://business.ohio.gov)
Your State Nursery Stock Producer's/Dealer's Certificate Number (if applicable)

(To obtain an Ohio Nursery Stock Producer's/Dealer's Certificate, call the ODA at 800 282-1955)
State Applicator's License Number (if applicable)

(To obtain an Ohio Applicator's License, go to: www.agri.ohio.gov)
Do you subcontract all your applications?
- Yes
- No
If yes, please list Vendor's Name
Membership Type
I am applying for
- Regular Membership
- Associate Membership

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Application for Membership

Business Information

Membership Type