NAME OF FIRM___________________________________________________

ADDRESS _______________________________________________________

_______________________________________________________

TELEPHONE (include area code) ____________________________________

FAX NUMBER (include area code) ___________________________________

EMAIL ADDRESS __________________________________________________

WEBSITE ADDRESS________________________________________________

NAME OF REPRESENTATIVE _____________________________________

Please provide a brief description of your (or your firms) interest in the banking profession. If you have an annual report, please include with application.

Please list the names and contact persons of any Vermont banks that you currently do business with or other references.

FOR OFFICE USE ONLY
Date received___________
Approval date __________
Dues notice ____________