WVPGA Membership Application

PO Box 11546

Company Name(Required)

Primary Contact Name(Required)

First Last

Email(Required)

Cell

HQ Mailing Address(Required)

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

Telephone(Required)

Website

Signature(Required)

Marketer, first retail location

Price:

Must also pay separate dues for the National Propane Gas Association

Quantity 1

Do you have more than one Retail location?

Yes

Additional locations

Price:

($300.00 x each additional retail and/or bulk plant location in West Virginia) Must also pay separate dues for National Propane Gas Association

Quantity 2

Associate Member

Price:

Quantity 3

Government Official/Entity

Price:

Quantity 4

Individual Member

Price:

(Those who wish to join as as individual member weather associated with or without a company membership.)

Quantity 5

Number of Bulk Plants

Total

Payment Method

Pay by Check

Pay by Credit Card

Instructions for paying by check will be provided on the registration confirmation page.

Billing Address

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

Credit Card