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. Membership Application & Update Form for Governmental Members Please choose what year you are paying due for. *2025 Dues2026 DuesChoose One *New MemberAnnual RenewalInformation Update Representative Name *Office Phone *Cell PhoneEmail * payment & Secure 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.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 - Governmental Members (ex. City of Pasadena TX)1$500.00Category and fair share dues - Smaller Cities1$250.00Secure online payment processing fee 4%1$0.00Total$0.00 $0.00Payment Method *Credit CardCheckPay with Credit Card *Card NumberMM123456789101112Expiration/YY2627282930313233343536Security CodePaying by Check? Please make checks payable to: Southeast Regional LEPC In the memo line list ‘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
