PermitTechNation 2020 Membership Application
PermitTechNation welcomes your application for membership. A copy of our current W-9 is available via this link https://drive.google.com/file/d/1W4hyQANjEzw2HtjagG4EAAITZz1QNMw3/view?usp=sharing

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Email address *
Is this a new application or renewal? *
If registering as an Individual Member, Individual Corporate or Corporate Member, please indicate the name of your Jurisdiction or Company. If you are registering a Chapter for membership, please indicate the name of the Chapter.
Name of Jurisdiction/State Chapter/Company you are registering under? *
Your answer
First Name *
Your answer
Last Name *
Your answer
Mailing Address *
Your answer
City *
Your answer
State (abbreviation only please) *
Your answer
Zip Code *
Your answer
Telephone # (xxx-xxx-xxxx format only please) *
Your answer
Email Address of Member or Chapter Representative *
Your answer
Chapter Voting Member Designee (enter first & last name of voting designee if filing for Chapter Membership)
Your answer
Are you an ICC Member? *
If you are an ICC Member, what is your member#
Your answer
Are you an ICC Certified Permit Technician? *
Membership Available:
Individual Member- You must be currently employed by a political subdivision or municipality for this membership type. Fee is $25

Chapter Membership - Any Association or Chapter whose members are employed by/for a governmental entity that is actively engaged in the administration and enforcement of building codes and all related ordinances. Please designate your voting member above. Fee is $100

Individual Corporate Membership: Any individual who works for an organization such as an association, society, testing laboratory, institute, university, college, company, manufacturer, or corporation interested in the purpose and the objectives of PermitTechNation. Fee is $50.00

Corporate Membership: Any organization such as an association, society, testing laboratory, institute, university, college, company, manufacturer, or corporation interested in the purpose and the objectives of PermitTechNation. Fee is $300

Special Membership: Special memberships may include but are not limited to Honorary Member, Retired Member and Student/Intern Member. (Must be approved by Board of Directors)
I am applying for the following membership type *
I wish to pay via *
Check Out Procedures
When paying via Check or Purchase Order, please print your email copy of the response and mail with the payment.

Mail to:
Dawn Neil, PTN Treasurer
c/o Bernards Township Building Dept.
277 S Maple Ave
Basking Ridge, NJ 07920

If paying via Credit Card please click the appropriate checkout link below; indicate the name of the PAYER (name of who the credit card belongs to) below so we can match the payment to the member.
For credit card payments indicate name of payer below ie: City of Sample or John Doe
Your answer
CREDIT CARD PAYMENTS-Choose one of the following links to pay by credit card. Please note you must be in either Chrome/Safari/Firefox, IE isn't supported.
A copy of your responses will be emailed to the address you provided.
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