* Applicants Name (Company Owner/s):    

Contact (If different than Applicant):

* Physical Address: 

Mailing Address (If different than physical address):

* City: 

* State:  --------------- Non-US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

* Zip Code: 

* Tax ID/SSN #:

* Business Phone: 

Alternate Phone:   

Fax: 

* Email: 

Website: 

* # of years in Business:

Please choose which membership you wish to apply for.

I/we apply for a Gold Card - 100% Trade

I/we acknowledge that by being a Gold Card member, I/we will trade at 100% A to Z Barter on every sale and purchase made between us and other Gold Card members.

Silver Card:

I/we apply for a Silver Card - 50%Cash /50% Trade

I/we acknowledge that by being a Silver Card member, I/we will trade 50/50 each time we sell or purchase, whether it be
between Gold or Silver Card members.

Changing card status:
Gold or Silver Card members may change from Silver to a Gold or Gold to a Silver Card if they wish,
however, there is a minimum term of 6 months.

Replacement card will cost members $15.00 cash. You must return your old card before a new card is issued.

Business Categories: (up to 3) :

1.

2.

3.

  Referred by:           

You must read and Agree to the Terms and Conditions.

View Terms and Conditions here.

* I/We have read and agree to the Term and Conditions as stated.

*I/We realize that by choosing the "Submit Form" button below, I/We have selected to submit an application for membership to A to Z Barter USA. Under the penalties of perjury, I/We (being the above listed applicant/s) certify that the information provided on this form is true, correct and complete and I agree to abide by the A to Z trading rules.