KPMA Supplier Membership Application

Supplier membership dues are assessed on a volume basis (combined gasoline and diesel sales in Kentucky for the previous 12 months), in gallons/year, which includes direct company operated outlets, commercial accounts and sales on which the supplier is liable for paying state tax to the Kentucky Department of Revenue. Please see below for dues amounts and select which reflects your company’s records for the year:

*

Less than 50 million gallons - $1,350
50 - 100 million gallons - $2,700
More than 100 million gallons - $4,050

Membership dues are prorated to the calendar month in which you join. Complete this form and mail with a check for dues payable to Kentucky Petroleum Marketers Association, 2365 Harrodsburg Rd., Suite A325, Lexington, KY 40504, or we will invoice you for the amount of your membership upon receipt of this form.

Name*

First Last

Job Title

Company*

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.

KPMA Supplier Membership Application

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