Albuquerque Bernalillo County LEPC
Online Membership Application


* = Required field

MEMBERSHIP TYPE *
NEW
RENEWAL
VOTING RIGHTS *
ASSOCIATE MEMBER WITHOUT VOTING RIGHTS
ACTIVE MEMBER WITH VOTING RIGHTS – MUST ATTEND 75% OF ALL       MEETINGS
First Name *:
Last Name *:
Title :
Agency:
Address *:
Address 2 :
City *:
State *:
Zip Code *:
Work Phone *:
Home Phone :
Fax :
Pager :
Mobile :
Email : *:
Why do you want to be a member of the LEPC?
(Optional)

What would you be able to contribute to the LEPC?
(Optional)

Which Sub-Committee(s) would you like to serve on?
Planning
Public Information
Finance
Resource – Business and Industry
Training – Exercise and Response
Transportation Commodity Flow Study Sub-Committee:
Highway
Rail
Air
Agency Affiliation (Please check one):
Municipal/State Government Local Elected Official
Law Enforcement Emergency Management
Fire Services EMS/Medical Response
Health Professional Local Environment
Hospital/Clinic Transportation
Broadcast/Print Media Community Agency
Facility Operator subject to
     EPCRA 		National Weather Service
Military Federal Facility
Correctional Facility Public Schools
University/College Private Citizen
Other (Please Specify)