Membership Form for Governmental Members Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Phone Pay Category Membership Application & Update Form ChooseNew MemberAnnual RenewalInformation Update Representative Name *Office Phone *Cell PhoneEmail * Member Category Company/Facility Name *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCategory and fair share dues *Governmental Members (ex. City of Pasadena TX) - $500.00Smaller Cities - $250.00Definitions: Such Members shall consist of duly elected or appointed officials of local, county, state, and federal governments with jurisdiction over any part of the area served by the SERLEPC and assigned responsibilities by The Act. Each governmental entity shall appoint one primary and one alternate representative.Total * Order Summary Item Quantity Qty Total There are no products selected. Category and fair share dues - Governmental Members (ex. City of Pasadena TX)1$500.00Category and fair share dues - Smaller Cities1$250.00Total$0.00 $0.00Pay with Credit Card *Card NumberMM123456789101112Expiration/YY2526272829303132333435Security CodeSubmit
