EPOC Member Application

EPOC New Member and Renewal Online Application Form

Please complete the form below to submit your membership information.
You must press "Submit" at bottom of form to send data.
If you're renewing EPOC membership and your contact information has not changed, you may enter only your name and e-mail address and we will continue to use your current contact data.
If you have any questions, please contact Seth Molofsky, Executive Director.

Membership Type:	New Membership, Renewal Membership
Full Name: (required)
Email: (required)
Company:
Address:
Address (cont'd):
City, State, Zip:
Phone: xxx-xxx-xxxx
Fax: xxx-xxx-xxxx
Select Membership Category:	Professional ($130) Associate ($65) Gov't/Student Professional ($65.00) Gov't/Student Associate ($32.50) Professional Members - All Members that are a Licensed Environmental Professional (LEP) as approved by the Board of Examiners or CTDEP. Associate Members - All Members not eligible to be Professional Members but who have a professional interest in the activities of EPOC and the CT DEP-LEP programs. Associate Members may not vote, hold office, or represent EPOC officially.
Directory Listing:	EPOC publishes our membership directory online which will include your name, address, phone, fax, and e-mail address. I wish to be listed in the EPOC Membership Directory: Yes, No
LEP/LSP Status (check all that apply):	CT LEP, MA LSP
Payment Options:	Will pay by: Credit Card Now, Check by mail
Comments/Questions:
	You must press "Submit" to send data.