Step 4: Member Information
Check only the services/products under the Membership type for which you are applying.
Contractor Members – check all services that your company provides:
❒ Bridge Buildings ❒ Docks and Wharves ❒ Marine
❒ Bulkheads ❒ Earth Retention ❒ Pile Driving
❒ Deep Dynamic Compaction ❒ General Contracting ❒ List Other Services:
❒ Deep Excavation ❒ Highway and Heavy Civil ____________________________________________
Associate Members – check all products and/or services that your company provides:
❒ Air Compressors & Pumps ❒ Hydraulic Power Packs ❒ Piles, Synthetic Material
❒ Coatings & Chemicals ❒ Leads & Spotters ❒ Piles, Timber
❒ Consulting ❒ Lubricants & Grease ❒ Rigging Supplies
❒ Cushions, Hammer ❒ Marine Drayage ❒ Safety Equipment
❒ Cushions, Pile ❒ Marine Equipment ❒ Sheet Piles, Aluminum
❒ Cutter Heads & Drill Bits ❒ Materials Testing ❒ Sheet Piles, Steel
❒ Design ❒ Other Structural Materials ❒ Sheet Piles, Vinyl
❒ Dock & Marine Supplies ❒ Pile Hammers ❒ Structural Steel
❒ Drilling Equipment & Supplies ❒ Pile Monitoring ❒ Surveying
❒ Drive Caps & Inserts ❒ Pile Points & Splices ❒ Testing
❒ Equipment Rental ❒ Piles, Composite ❒ Trucking
❒ Equipment Sales ❒ Piles, Concrete ❒ Vibration Monitoring
❒ Freight Brokerage ❒ Piles, Steel H List ❒ Other Services:
❒ Hoses & Fittings ❒ Piles, Steel Pipe ____________________________________________
Engineering Affiliate – check all products and/or services that your company provides:
❒ Analysis ❒ Geotechnical ❒ List Other Services:
❒ Civil ❒ Surveys ____________________________________________
❒ Consulting ❒ Structural ____________________________________________
Step 5: Geographic Areas Where Services and Products Are Available
Check all that apply
❒ All States ❒ AK ❒ AL ❒ AR ❒ AZ ❒ CA ❒ CO ❒ CT ❒ DC
❒ DE ❒ FL ❒ GA ❒ HI ❒ IA ❒ ID ❒ IL ❒ IN ❒ KS
❒ KY ❒ LA ❒ MA ❒ MD ❒ ME ❒ MI ❒ MN ❒ MO ❒ MS
❒ MT ❒ NC ❒ ND ❒ NE ❒ NH ❒ NJ ❒ NM ❒ NV ❒ NY
❒ OH ❒ OK ❒ OR ❒ PA ❒ RI ❒ SC ❒ SD ❒ TN ❒ TX
❒ UT ❒ VA ❒ VT ❒ WA ❒ WI ❒ WV ❒ WY ❒ Canada ❒ Mexico
❒ South America ❒ Europe ❒ Asia ❒ Other _______________________________________________________________________
Step 6: Payment Representative (Please Choose)
Membership Type . $______________ Louise Peterson ❒
PDPI Contribution. .$______________ Quinn Bogusky ❒
Optional Employee/Office. .$______________ Walter Lytwyn ❒
Membership Upgrades. .$______________ Darryl Sawchuck ❒
Total:. .$______________ N/A ❒
Type of Payment
I am making payment in full by: ❒ Check ❒ Visa ❒ MasterCard ❒ American Express ❒ Discover
Card Number: ________________________________________________________________ Expiration Date: �
Name on Card: _ ______________________________________________________________ CVV Code: �
Statement Billing Address: ________________________________________________________________________________________________________________________
Signature: _________________________________________________________________________________________________________________________________________
Please complete this application and mail to:
PDCA – 33 Knight Boxx Road, Suite 1, Orange Park, FL 32065 or Fax to: 904-215-2977
Perforated for easy removal