30 West Lafayette Street

Trenton, NJ 08608

609-392-8899

609-396-6571 Fax

www.njfoodcouncil.com

2009 APPLICATION FOR RETAIL MEMBERSHIP

Please enroll my firm as a Member of the New Jersey Food Council.  My firm is engaged primarily in food retailing in the State of New Jersey.  Total sales volume of all NJ food retailing outlets of this firm for the preceding calendar year ending December 31st was ______________.  Based upon this sales volume, the current annual dues for my firm are $_______________. 

Check enclosed: _______      Please send invoice:  _________  Credit card charge: __________

MC___Visa___Card#_________________________Exp:__/__      Signature: ____________________________

Please print or type.

FIRM NAME: __________________________________________________________________________________________

ADDRESS:     __________________________________________________________________________________________

CITY/ST/ZIP: __________________________________________________________________________________________

CONTACT(S):  _____________________________________________ ___________________________________________

(Up to 3)                                Name                                                                                                      Title

                            _____________________________________________ ___________________________________________

                                                Name                                                                                      Title

                            _____________________________________________ ___________________________________________

                                                Name                                                                                      Title

PHONE/FAX:   _____________________________________ ___________________________________

                                Phone                                                                      Fax

E-MAIL           _________________________________________________________________________

#NJ EMPLOYEES:  _______  #NJ STORES: _______

DUES SCHEDULE                                                                              SUGGESTED

SALES VOLUME DUES PAC CONTRIBUTION

    0-5 Million                    $193.00                                                                 $50

    5-10 Million                  $637.00                                                                 $50

  10-25 Million                  $898.00                                                                 $50

  25-50 Million               $2,243.00                                                               $200

  50-100 Million             $4,449.00                                                               $200

100-150 Million             $6,731.00                                                               $200

150-250 Million             $8,974.00                                                               $400

250-500 Million           $11,220.00                                                               $400

Over 500 Million          $14.210.00                                                               $400

Contributions or gifts to NJFC are not deductible as charitable contributions for Federal Income Tax purposes.  However, they may be tax deductible as ordinary and necessary business expenses subject to restrictions imposed as a result of association lobbying activities.  NJFC estimates that the nondeductible portion of your Dues-the portion which is allocable to lobbying- is 15%.      EIN:  22-1863080

Thank you for your support.