Office of Emergency Management

Membership Application

(Effective Date: 2008 - 2009)

LOCAL EMERGENCY PLANNING COMMITTEE
2009 Executive Board

Todd Gregory - Chair
Tim Zagorski - Vice Chair
Ron Camnunez - Secretary
Carey Latesa - Treasurer
Delia Cervantes - OEM Representative

Please complete as much of the form as you can. Fields with an asterisk (*) are required.

* Membership Type
New
Renewal

* Voting Rights
Member Without Voting Rights
Member With Voting Rights - Amount Due $20.00 (per year)

* Name:
Title:
Agency:
Address:
City/State/Zip:
Work Phone:
Home Phone:
Fax:
Pager:
Mobile:
* E-mail:

Why do you want to be a member of the LEPC?

What would you be able to contribute to the LEPC?

* Which Sub-Committee(s) would you like to serve on?
Committee Awareness / Education / Membership
Exercise / Planning / Development
Finance

* Which All Hazard Emergency Operation Planning Committee(s) would you like to serve on?
Hazmat Facility / Transportation
Public Health and Medical
Natural Hazard

* Agency Affiliation (please select 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

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Office of Emergency Management

Membership Application

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