Refiner/Wholesaler 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
Please check the petroleum products, listed below, that are available from your company.*
- Gasoline
- #2 Fuel Oil
- Diesel
- Propane
- Kerosene
- Lubricants, Industrial
- Lubricants, Automotive
- Residual
- Other
Please Specify
Additional Mailings ($30 each)
Extra Mailings Price
Total Fees Due:
Price: $0.00
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*
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Associate Members – Refiners/Wholesale Suppliers are petroleum marketers who supply other independent branded and non-branded petroleum marketers that sell gasoline, heating oil, diesel fuel, kerosene, propane and other petroleum products.

Download Refiner/Wholesaler Membership Application PDF

Refiner/Wholesaler Application

Refiner/Wholesaler Application

ADDITIONAL MAILING ADDRESSES