Retail C-Store Operator 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
RETAIL C-STORE OPERATOR MEMBERSHIP
$300 ANNUALLY 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.
Indicate Number of Owned/Operated Stores*
- 1 Store
- 2 Stores
- 3 Stores
- 4 Stores
- 5+ Stores (would pay dues according to annual gallons)
GALLONAGE
Gasoline
Diesel
Total Gallons
Total Dues
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
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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

This membership category is specifically designed to meet the needs of the small retail operator. You must own and operate at least one (1) and no more than four (4) retail convenience stores to be eligible for membership in this category.

Download Retail C-Store Operator Membership Application PDF

Retail C-Store Operator Application

Retail C-Store Operator Application

RETAIL C-STORE OPERATOR MEMBERSHIP

GALLONAGE