PECA Membership Application

Company Name

Mailing Address

City State Zip

Representative

Alternate Representative

Phone Number

Fax Number

Email Address

Website Address

Business Entity

Individual Partnership Corporation

Business Started (Mo./Date/Yr.)

Years In Present Business Form

Associate Membership Requirements

List Type Of Business

Relationship To Petroleum
Equipment Installation Industry

Type Of Membership Requested

Active Associate Mfg/Rep

Active Membership - Fill in all that applies. Use company License Number Only.

NJ Weights & Measures Company Only	License No.
NJ Underground Storage Tank Certification	License No.

Installation - Check all items you are licensed for.

	Entire UST System
	Release Detection Monitoring System Only
	Closure
	Tank Testing
	Substance Evaluation

Corrosion Protection System Analyst

	Cathodic Protection Specialist
	Cathodic Protection Tester Only

Sponsors

List two (2) existing PECA member companies' names you feel would sponsor your application.

Sponsor #1

Sponsor #2

I would like to be considered for participation on the following committees.

Advertising	Education and Safety
NJ Government Affairs/B.U.S.T.	Membership

List qualifications or expertise you posses that would enhance this Association.

Applicant's Signature

Type or Print Name

Date

Print Application and Mail To:

Do not send a check with this application. Upon your acceptance, a letter will be sent to you along with a prorated dues' bill.

Thank you for your desire to join the Petroleum Equipment Contractors Association of New Jersey.

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