Emergency Response Telephone Number - Membership Application

Company Information

* Name of Company:

* Name of Correspondence Person:

* Business Phone:

Fax:

* Email Address:

* Street Address (Physical Location):

* City:

* State:

* Zip:

Is your Mailing Address the same as above?:

Yes No

Emergency Contact Information

Emergency Contact #1

* Name:
* Home Phone:
Cell Phone or Pager:

Emergency Contact #2

Name:
Home Phone:
Cell Phone or Pager:

Emergency Contact #3

Name:
Home Phone:
Cell Phone or Pager:

- less contacts | more contacts +

Local Emergency Information

* Fire Department (Name, Number):

* Police/Sheriff Department (Name, Number):

Hazardous Materials Clean-up Company (Name, Number):

Types of Coverage

Transportation Coverage [?]:

Bulk Storage Coverage [?]:

Which best describes your company?

	Petroleum Marketer/Carrier		Gases and Welding Supply Distributor
	Propane Marketer/Carrier		Home/Medical Oxygen Distributor
	Construction		Agriculture
	Shipper Using Common Carrier		None of the Above

Do you have Additional Locations (branches or storage)?:

Yes No

Note: A PERS representative will contact you to complete the account setup process. We will determine
what shipping papers are appropriate (if applicable) and discuss additional locations you may wish to cover.
We will also discuss the total cost for your emergency number coverage. Upon approval, we will invoice
your company for the annual fee, based on the number and type of locations covered.

Emergency Response Telephone Number - Membership Application

National Threat Level:

Products Profile

Services Profile