:: WORLDCOB ::

COMPANY INFO

I. COMPANY INFORMATION: Please complete the following information. (*) Required

* Company Name:

* Representative:

* Activity:

Number of Employees:

Last year´s sales / Currency:

*Address:

Postal Code:

* State or City:

* Country:

* Date of Incorporation: (dd/mm/yyyy)

* TAX ID:

* Phone Number(s):

* Fax:

* E-mail:

* Name of company President or Director:

* Title:

* Email:

* Direct or Mobile Phone:

* Contact Person:

* Title:

* Email:

* Direct or Mobile Phone:

2. TOTAL US$ ANUAL MEMBERSHIP

Participation: US$

Note: I have read all of the WORLDCOB MEMBER benefits

and I accept the annual membership.