New York Propane Gas Association

New York Propane Gas Association P.O. Box 760 Clifton Park, NY 12065 Phone: (518) 383-3823 Fax: (518) 383-3824 Email: [email protected] Membership Application

The following information is submitted to apply for membership in the New York Propane Gas Association;

COMPANY NAME:

MAILING ADDRESS (PO Box):

PHYSICAL MAILING ADDRESS (required):

CITY: STATE: _____ ZIP: COUNTY: ______

BUSINESS PHONE: (_____)______FAX: (______)

NAME OF PRIMARY REPRESENTATIVE:

EMAIL ADDRESS: SIGNATURE:

NAME OF ALTERNATIVE REPRESENTATIVE:

EMAIL ADDRESS:

DATE OF APPLICATION:

REFERENCE - INDIVIDUAL OR COMPANY (required):

MEMBERSHIP CLASSIFICATION - Check appropriate classification

__ Bulk Plant Only __ New Member (first time)

__ Retail Location Only __ Reinstate (former) Member

__ Bulk Plant & Retail Location

______INTRA STATE MARKETER BASIC DUES $697.00 includes 1 bulk plant $______PLUS $145 for each additional bulk plant in NY $______TOTAL $______

______MULTI STATE MARKETER BASIC DUES $697.00 $______PLUS $200 each bulk plant (1-25 bulk plants in NY) $______PLUS $145 each bulk plant (26-50 bulk plants in NY) $______TOTAL $______

______ASSOCIATE MEMBER $275.00 $______

______INDIVIDUAL $100.00 $______

Please make check payable to: New York Propane Gas Association, and return to the Association address above.

Association Membership is Good Business!