KPMA C-Store Membership Application

C-Store membership annual dues are assessed by number of C-Stores or Service Stations. See below for membership dues levels and choose which applies to you (more than three stores qualifies for Marketer application):
- One C-Store or Service Station - $100
- Two C-Stores or Service Stations - $200
- Three C-Stores or Services Stations - $300
Membership dues are prorated to the calendar month in which you join. 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.
Name*
First Last
Job Title
Company Name
Company Address*
Street Address Address Line 2 City State ZIP Code
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
After submission of this form, KPMA will email you a copy of your invoice.

Questions? Contact KPMA at 859.219.3571 or email kpma@kpma.org.

Interested in Membership?