KPMA Marketer Membership Application Jobber membership dues are assessed on a volume (combined gasoline and diesel sales in Kentucky for the previous 12 months) basis, in gallons/year. Please see below for dues amounts, and select which reflects your company's records for the year:* Less than 1.5 million - $535 1.5 - 2.5 million - $625 2.5 -3.5 million - $935 3.5 - 4.5 million - $1,245 4.5 - 5.5 million - $1,560 5.5 - 6.5 million - $1,870 6.5 - 7.5 million - $2,180 7.5 - 10 million - $2,495 10 - 15 million - $2,675 15 - 20 million - $2,970 20 - 25 million - $3,265 25 - 30 million - $3,565 30 - 40 million - $3,860 40 - 50 million - $4,160 50 - 60 million - $4,455 60 - 70 million - $4,750 70 - 80 million - $5,050 80 - 90 million - $5,345 90 - 100 million - $5,645 More than 100 million - $5,940 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* Company Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this address also your billing address?* Yes No Billing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail* Enter Email Confirm Email Website* Description of Products*How did you hear about us?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.CommentsThis field is for validation purposes and should be left unchanged.