Company Name

Contact Name

Company Address

Phone Number

Email

Website

Products / Services eligible for discount

What is the discount / special offer?

Is this discount of greater value than what is offered to the general public? Is this discount of greater value than what is offered to the general public? Yes No

How do MCA members receive the discount?

Are there any exclusions or restrictions?

How long will the discount be valid?

Where is this discount valid? Where is this discount valid? All Locations Select Locations

Please list all locations where the discount can be received.

How did you hear about the MCA vendor discount program? How did you hear about the MCA vendor discount program? Website Social Media Member Other

Confirmation Confirmation By selecting this box I confirm that I understand that the products and services listed in the Member Discount Program are provided as a service to MCA members and do not constitute an endorsement by MCA. MCA makes no warranties, expressed or implied, including the warranty of merchantability or fitness for a particular purpose regarding any products or services listed in the MCA Member Discount Program. By selecting this box I confirm that I have read the "MCA Guidelines for Approval of the Discount Listing" in the MCA Member Discount Program packet and certify that the discount stated above complies with these guidelines MCA Member Discount Guidelines

Date