Membership Application

Secure Energy for America



	RPSEA 1650 Highway 6 Suite 325 Sugar Land, TX 77478 (281) 313-9555

Membership Application
Please completely fill out the Membership Application. Section 1: The fields with a red* are required. Section 2: Choose your Membership Type. Example, if you are an Academic Institution, your membership dues will be $2,500.00 You will be invoiced after your membership is approved. Section 3: The payment section should have User requested the invoice be sent selected. Security Box: Enter the code exactly as displayed in the box below it. If you are unable to read the code, click on the speaker icon to the right of the code to hear the code. This is a security feature to protect your information. Click "Submit Membership Application" button. You will then emailed a confirmation page with further information about the approval process.


Section 1: User Information
Web Site*

Salutation

First Name*

Initials

Last Name*

Title*

Company*

Address*

Address 2

City*

State*

Zip Code*

Phone*

Fax

E-mail*

Section 2: Membership Type

Membership Type*

	$10,000.00 - Commercial Company Annual Revenue >$100M
	$5,000.00 - Commercial Company Annual Revenue <$100M >$30M
	$1,000.00 - Commercial Company Annual Revenue <$30M
	$2,500.00 - Academic Institution
	$1,000.00 - Non-Profit Organization/Trade Association
	$2,500.00 - State/Federal Government Entity


Section 3: Payment
Payment Method* Send invoice


For security reasons, type in the code below:

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