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WISCONSIN INDEPENDENT CONTRACTORS DIVISION

APPLICATION

(Please fill out your information in the boxes below and then print out the form.)

Company Name
Contact Name
Title
Mailing Address
Street Address
City
State
Zip Code
Local phone
Fax
Watts
Email

Website:
 
Annual Dues Schedule:
INDEPENDENT CONTRACTORS


$84
 

Payment options: Check enclosed Bill me Charge to my credit card

If you are charging your dues on your credit card, please enter information in the boxes below.

Credit card#:  (Numbers only) Exp date: (mm/yyyy)

Please print this form out and either mail or fax it to:

Wisconsin Independent Contractors Division
P.O. Box 44849
Madison, WI  53744-4849
Fax: (608) 833-2875

Copyright 1999
This page last updated: October 27, 2007