Application

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Organization Information (to be displayed online)

Organization Name

Address 1

Address 2

City

State

Zip

Company Phone

Company Fax

Website

Main Contact

Copy from Organization-Information

First Name

Last Name

Title

Office Phone

Mobile Phone

Newsletter Subscription YesNo

Magazine Subscription YesNo

Directory Listing YesNo

Billing Address (if different)

Address 1

Address 2

City

State

Zip

Additional Information

Please have someone contact me regarding

Partner Programs
Sponsorship Opportunities
Speaker Opportunities
Legislative and Regulatory Issues
Networking
Educational Events
Other

Government Party

House District

Senate District

IPECA Equipment Contractor Membership YesNo

Expiration Date

Last Renewal Date

Membership Investment

Membership Type

Primary Directory Category

Number of Locations

Number of Gallons (In Millions)

IPECA Membership YesNo

PAC Donation

Annual Membership Investment

Tax

Total

Payment Type

NOTE: If you would prefer to pay by Check, please reach out to Cathy Melton at 317-655-4448. Thanks!

Credit Card Information

Copy from Organization Information

Credit Card Type MastercardVisaDiscoverAmex

Credit Card Number

Name on Card
Security Code
Valid Through
Address
City
State
Zip
Phone
Credit Card Email Address

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Application