Mail To:                                             Date:____/____/____

Dana Quigley

Bristle Chimney Sweeps, Inc.

921 Walsh Rd, Suite 210

Madison, WI   53714

(608) 249-6678


Current Dues: $75.00



Business Name:


Owners Name:




City:                                     State:                   Zip:






How long have you been in business?                          Full or Part time?

Do you have another occupation?


Are you a member of any other business organizations?


Do you hold any certifications or licenses?(If yes, please give expiration dates if applicable.)



Have you attended any chimney seminars?


What type of cleaning equipment do you own?


How many vehicles do you have on the road?


Who is your business liability carrier and the amount of coverage?


How many employees do you have?


What type of services do you offer?





Office Use Only:

Accepted/Rejected       Date:___/___/____  Reason:______________________________________________________________________

Full Membership ______   Associate Membership_____  Newsletter Only_____

Yearly Fees that apply_________________

Other Notes:_________________________________________________________________________________