Sample Membership Application

Sample Membership Application Section 1: Company Information Main Company Contact Person: Mayor Pike Company Name: Mayberry Public Works Mailing Address: 1234 Main St Email: [email protected] City: Mayberry State: AL Zip Code: 35608 Physical Address: Company Mailing Address Same as Mailing Address: ☒ City: City State: State Zip Code: Zip Code Office Phone: 555-555-5555 Office Fax: 555-555-5556 Company Website Address: https://www.visitmayberry.com/ Section 2: Hours of Operation List the hours that your company will have someone available to monitor locate request delivery. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Open Time 7 7 8 7 7 Close Time 5 5 4 5 5 24 Hour ☐ Selecting this option indicates that your company will monitor and respond to the primary receiving device at all times (24x7) and will not require after-hour emergency notifications. Section 3: Facility Type Type of facilities operated – select all that apply: ☐Cable Television ☐Gas Transmission ☐Water Gathering ☒Electric ☐Long Distance Carrier ☐Other: ____________ ☐Fiber ☐Product Pipeline ☐Gas Distribution ☒Sewer ☐Gas Gathering ☐Telephone ☐Gas Interstate Pipeline ☒Water Section 4: Locate Request Receiving Information Choose mode of receiving locate requests and daily audit reports: ☒Email Address: [email protected] ☐KorWeb: If you choose this option someone will contact you to set up your KorWeb account ☐FTP: Address Username Password Remote Directory Name (If needed) Daytime Backup (if phone call is needed): Name of Person or Dept. Floyd Lawson Phone: 555-555-5553 Do you want to receive copies of locate requests you have requested? ☐Yes ☒No Section 5: Survey / Design Requests This section is only required to be completed if you would prefer to have survey design requests sent to a separate receiving device in addition to your normal receiving device. Email Address: [email protected] Name of Contact Person or Dept. Ellie Walker Phone Number 555-555-5552 Section 6: Operating Hour Emergency Locate Request Tickets This section is only required to be completed if you would prefer to have emergency requests sent to a separate receiving device in addition to your normal receiving device. Email Address: Email address Name of Contact Person or Dept. Name Phone Number Phone Section 7: After Hours Emergency Contact Information: This section is not required to be completed. This section should only be completed if you wish to receive a courtesy call letting you know that an emergency locate request ticket has been sent to your company outside of your normal hours of operation. In addition to this call, you will also be sent a copy of the emergency locate request by normal delivery. Primary Contact: Andy Taylor Phone: 555-555-5551 Alt Phone: Number Alternate Contact #1: Barney Fife Phone: 555-555-5550 Alt Phone: Name Alternate Contact #2: Name Phone: Name Alt Phone: Name May this information be provided to our callers? ☒Yes ☐No Section 8: Notification Area Information Name of authorized contact person for notification / service area updates: Ellie Walker Mailing Address: Address Same as Mailing Address: ☒ City: City State: City Zip Code: City Email Address: [email protected] Phone: 555-555-5552 Section 9: Billing Information Name of Billing Contact Person: Howard Sprague Billing Address: Company Mailing Address Same as Mailing Address: ☒ City: City State: State Zip Code: Zip Code Office Phone: 555-555-5555 Office Fax: 555-555-5556 Email: [email protected] Would you prefer to receive your invoices by ☐ Mail or ☒Email Preferred Billing Frequency: Annual: ☐ Quarterly: ☒ Monthly: ☐ Section 8: Positive Response Name of person posting responses: Gomer Pyle Cell Phone: 555-555-5432 Email Address: [email protected] Office Phone: Phone Do you have an existing AL811 WebPortal account? ☒Yes ☐No Please select each facility type that you will be responding for: ☐Cable Television ☐Gas Interstate Pipeline ☐Telephone ☒Electric ☐Gas Transmission ☒Water ☐Fiber ☐Long Distance Carrier ☐Water Gathering ☐Gas Distribution ☐Product Pipeline ☐Other: _____________ ☐Gas Gathering ☒Sewer Form Completed By: Name: Andy Taylor Phone: 555-555-5551 Signature: Andy Taylor Date: 1/22/2021 To be completed by AL811 Member Code: MBRY01 Activation Date: 10/3/1960 AL811 Responsible: Matt .

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