Membership Form for Affiliate Members Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Membership Application & Update Form for Affiliate Members Please choose what year you are paying for. *2025 Dues2026 DuesChoose One *New MemberAnnual RenewalInformation Update Representative Name *Office Phone *Cell PhoneEmail * Affiliate Member Category Company/Facility Name *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCategory and fair share dues *Transportation Companies - $500.00Product Warehouses - $500.00Pipeline Companies - $750.00All Others - $250.00Definitions: Such members shall consist of representatives from communications media, health professionals, environmental groups, homeowners’ associations, and citizens groups located within the cities listed in Article II.D . In addition, this category includes individuals from business that are classified as Health Safety and Environmental (HSE) partners with responsibility and/or interest in matters for the cities listed in Article II. D. Each Affiliate shall appoint one primary and one alternate representative.Secure online payment processing fee 4% *Price: $0.00Total * Order Summary Item Quantity Qty Total There are no products selected. Category and fair share dues - Transportation Companies1$500.00Category and fair share dues - Product Warehouses1$500.00Category and fair share dues - Pipeline Companies1$750.00Category and fair share dues - All Others1$250.00Secure online payment processing fee 4%1$0.00Total$0.00 $0.00Payment Method *Credit CardCheckPay with Credit Card *Card NumberMM123456789101112Expiration/YY2627282930313233343536Security Code Total Company/Facility fee Paying by Check? Please make checks payable to: Southeast Regional LEPC In the memo line list ‘Affiliate Membership Dues’ Check NumberIf you do not currently have a check available, please submit the form and include the attached invoice when mailing your payment. You will receive the invoice after submitting the form.Submit
