<p> 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</p><p>The following information is submitted to apply for membership in the New York Propane Gas Association;</p><p>COMPANY NAME: </p><p>MAILING ADDRESS (PO Box): </p><p>PHYSICAL MAILING ADDRESS (required): </p><p>CITY: STATE: _____ ZIP: COUNTY: ______</p><p>BUSINESS PHONE: (_____)______FAX: (______) </p><p>NAME OF PRIMARY REPRESENTATIVE: </p><p>EMAIL ADDRESS: SIGNATURE: </p><p>NAME OF ALTERNATIVE REPRESENTATIVE: </p><p>EMAIL ADDRESS: </p><p>DATE OF APPLICATION: </p><p>REFERENCE - INDIVIDUAL OR COMPANY (required): </p><p>MEMBERSHIP CLASSIFICATION - Check appropriate classification </p><p>__ Bulk Plant Only __ New Member (first time)</p><p>__ Retail Location Only __ Reinstate (former) Member</p><p>__ Bulk Plant & Retail Location</p><p>______INTRA STATE MARKETER BASIC DUES $697.00 includes 1 bulk plant $______PLUS $145 for each additional bulk plant in NY $______TOTAL $______</p><p>______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 $______</p><p>______ASSOCIATE MEMBER $275.00 $______</p><p>______INDIVIDUAL $100.00 $______</p><p>Please make check payable to: New York Propane Gas Association, and return to the Association address above.</p><p>Association Membership is Good Business!</p>