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Corporate / Multi-line Members Profile

Company Name:

Contact Person:

Position:

Address:

City:

State/CD:

Zip:

Country Name:

Work Phone:

Toll Free:

Fax Phone:

Email:

Website:

Chapter Affiliation(s):

Number of years promoting/selling AFRICA:

Company Description for APTA Website: (50 words or less)

Countries / Products Promoted:

Office Hours:

Travel Industry Affiliations & Memberships:

Referred By:

2010 Corporate Membership Dues $350.00 2010 Multi-line Membership Dues $550.00

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Total Due:

Check Wire Transfer Already Paid

CHECKS PAYABLE TO APTA Please send to: Yvette De Vries Director of Corporate Membership African Portfolio 146 Sound Beach Avenue Old Greenwich, CT 06870 USA WIRE TRANSFERS: (Please add $25.00 to your payment for bank fees) Bank: The Suffolk County National Bank 74 Echo Avenue Miller Place, New York 11764 Phone: 631-474-8400 Account: Association for the Promotion of Tourism to Africa. Account: # 1320011347 Routing: # 21405464 Thank you for your prompt payment!