Active Member Application

Company*
Company Representative Name & Title (Name to be shown in Directory)*
Street Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Email
Website
Mailing address is different than street address above
- Yes
- No
Mailing Address
Street Address Address Line 2 City State ZIP Code
ADDITIONAL MAILING ADDRESSES
The designated company representative, listed above, receives a mailing as part of the dues payment. Additional mailings to other employees of the company may be added at $30.00 each, annually. Please list additional mailing(s) below.
I would like to add an additional mailing address
- Yes
- No
Company Representative 2*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
I would like to add a third mailing address
- Yes
- No
Company Representative 3*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
I would like to add a fourth mailing address
- Yes
- No
Company Representative 4*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
I would like to add a fifth mailing address
- Yes
- No
Company Representative 5*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
I would like to add a sixth mailing address
- Yes
- No
Company Representative 6*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
I would like to add a seventh mailing address
- Yes
- No
Company Representative 7*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
I would like to add a eighth mailing address
- Yes
- No
Company Representative 8*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
I would like to add a ninth mailing address
- Yes
- No
Company Representative 9*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
I would like to add a tenth mailing address
- Yes
- No
Company Representative 10*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State ZIP Code
GALLONAGE
Gasoline
#2 Fuel Oil
Diesel
Kerosene
Total Gallons
Total Gallons Price
Total Gallons Price
Total Gallons Price
Total Gallons Price
Total Gallons Price
Total Gallons Price
Total Gallons Price
Does your company sell propane?
- Yes
- No
ACTIVE MEMBER INFORMATION

IN ORDER FOR US TO BE ABLE TO REPRESENT THE ENTIRE PPA MEMBERSHIP AND TO PROVIDE STATISTICAL INFORMATION, IT IS VERY IMPORTANT THAT YOU COMPLETE THE ACTIVE MEMBER INFORMATION. ALL INFORMATION ON YOUR APPLICATION IS KEPT STRICTLY CONFIDENTIAL.
Residential Home Heating Accounts
Commercial Fuel Accounts
Delivery Trucks
Transports
Other Vehicles
Employees
C-Stores
Stations Controlled
Stations Supplied
BRAND 1 (Gasoline)
BRAND 2 (Gasoline)
BRAND 3 (Gasoline)
Additional Mailings ($30 each)
Extra Mailings Price
Total Dues:
Total Dues:
Total Dues:
Total Dues:
Total Dues:
Total Dues:
Total Dues:
Choose your payment method:
- Invoice Me
- Pay Now
Credit Card

American Express
Discover
MasterCard
Visa
Consent*
By typing my name below I am consenting that this is my electronic signature and grant PPA the permission to use the information above. The information in the above form is completed and true to the best of my knowledge.*
Electronic Signature*
CAPTCHA

Active Members are independent branded and non-branded petroleum marketers who sell gasoline, heating oil, diesel fuel, kerosene, propane and other petroleum products at both the wholesale and retail levels, including convenience stores.

Download Active Member Membership Application PDF

ACTIVE DUES SCHEDULE

MOTOR FUELS AND HEATING FUELS (Gallons)

0 – 999,999

$500.00

1,000,000 – 1,999,999

$1,000

2,000,000 – 4,999,999

$1,250

5,000,000 – 9,999,999

$2,000

10,000,000 – 14,999,999

$3,000

15,000,000+

$4,000

The above dues are based on total gallons of motor fuels (gasoline and diesel) and heating fuels (kerosene and fuel oil—distillate), except those sold under the fill to another distributor. This includes retail gallons at member-operated locations. In the case of multiple operations, membership should reflect all gallons from combined operations, unless each operation is enrolled as a member.

Active Member Application

Active Member Application

ADDITIONAL MAILING ADDRESSES

GALLONAGE

ACTIVE MEMBER INFORMATION

ACTIVE DUES SCHEDULE