Member Update Form Please call if you have any questions (207-729-5298). 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*FaxKey personnel*Job/TitleNameEmail AddressPhone 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 personnelWho 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 TypePlease choose which best describes your membership?Dealer MemberAssociate MemeberDealer MemberThe 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 FormThe 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 Accounting Air Conditioning Banking & Finance C Store Equipment Common Carrier Computer Services Consulting Electrical Serices Environmental Services Excavation/Earth Moving General Industry Equipment Heating Equipment/Supply Heating System Installation/Service Insurance Plumbing Propane Tanks and/or Equipment Refrigeration Sales and/or Service Tanks (General Storage Purpose) Trailer Sales and/or Leasing Truck Sales, Service, and/or Repair UST/AST Tank Installation Other? How many employees do you have? 1-15 16+ NameThis field is for validation purposes and should be left unchanged. Δ