Company Name*

Best Contact Email*

Address*

If you use a P.O. Box for mailing purposes please also supply us with your physical address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Key personnel*

Job/Title	Name	Email Address	Phone

Please provide details for all personnel below that apply to your organization. Those listed here will be included in electronic email blasts, as well as topic appropriate paper mailings (unless you specify otherwise). Examples: President, CEO, Human Resources, Service Manager. Use '+' to add multiple personnel

Who above should be the Key or Primary Contact for your company?*

First Last

Are you interested in finding out more about MEMA’s Self Insured Health Insurance Trust?*

Yes
No

Are you interested in finding out more about MEMA’s Self Insured Workers Compensation Trust?*

Yes
No

Do you or anyone in your organization enjoy reading the MEMA MAG?*

Yes
No

Do you or anyone in your organization enjoy reading the weekly MEMA Random?*

Yes
No

Membership Type

Please choose which best describes your membership?

Dealer Member

The below information is pertinent for accurate dues calculation. It is kept strictly confidential. Please call Hannah if you have any questions at 207.729.5298.

Average Gallons Sold (or Previous Winter) of Oil, Kerosene

Average Gallons Sold (or Previous Winter) of BioFuels

Average Gallons Sold (or Previous Winter) of Propane

Average Gallons Sold (or Previous Winter) of Off Road Diesel

Associate Member Update Form

The MEMA Membership Directory will carry a complete listing of associate members and the various services they provide. These listings allow current and Prospective customers to find you easily. In order for us to successfully complete this listing, it is important for you to tell us which categories you wish to be listed in. Place a check mark next to those that apply.

Associate Member Categories

How many employees do you have?

1-15
16+

Comments

This field is for validation purposes and should be left unchanged.

Member Update Form

Membership Type

Dealer Member

Associate Member Update Form

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