KPMA Associate Membership Application

KPMA welcomes associate businesses to join the KPMA. Dues for associate members are $475 per year. Please provide detailed information about your company and services below:

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Name of principle representative

Name*

First Last

Job Title

Company*

Company Address*

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

Is this address your billing address?*

Yes
No

Billing Address

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Enter Email Confirm Email

Website

Description of product/services:*

How did you hear about us?

Complete this form and mail a check for dues to Kentucky Petroleum Marketers Association, 2365 Harrodsburg Road, Suite A325, Lexington, KY 40504, or we will invoice you for the amount of your membership upon the receipt of this form.

After submission of this form, KPMA will email you a copy of your invoice.

Questions? Contact KPMA at 850.219.3571 or email kpma@kpma.org.

Phone

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

KPMA Associate Membership Application

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