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 - $1,35050 - 100 million gallons - $2,700More than 100 million gallons - $4,050Membership 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 Company*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is*YesNoBilling Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*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@campwolf.com