Membership Form for Industrial 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 Industrial Members Choose One *New MemberAnnual RenewalInformation Update Representative Name *Office Phone *Cell PhoneEmail * and Industrial Member 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 *Industrial Members - $500.00EPCRA Definitions: Manufactured = to produce, prepare, import, or compound a toxic chemical. Process = the preparation of a toxic chemical, after its manufacture, for distribution in commerce, (1) in the same form or physical state as, or in a different form or physical state from, that in which it was received by the person so preparing such chemical, or (2) as part of an article containing the toxic chemical.Total number of employees; contractors (nested/core) *Price: 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purposes of fee calculation, the definition of an employee is company employees plus nested/core contract personnel x 4.50 per person)Siren Support *Price: $1,000.00(A contribution towards the ongoing operational costs of the siren system. This also covers connected services for remote diagnostics from the manufacturer, as well as troubleshooting, minor repairs and ongoing maintenance for each siren site)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 - Industrial Members1$500.00Total number of employees; contractors (nested/core)0$0.00Siren Support1$1,000.00Secure online payment processing fee 4%1$0.00Total$1,000.00 $0.00Pay with Credit Card *Card NumberMM123456789101112Expiration/YY2526272829303132333435Security CodeSubmit Prefer to pay by check? Avoid transaction fees by paying with a check. Download the Membership Form. Make payment to: SERLEPC PO Box 1148 Pasadena, TX 77501 Download Here
