Office of Emergency Management

About LEPC Membership Form

LOCAL EMERGENCY PLANNING COMMITTEE
2009 Executive Board

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

Membership Application Effective Date: 2008 – 2009

All fields are required to be filled out. If a field does not apply, please put NA.

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:
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?
Committee Awareness / Education / Membership
Exercise / Planning / Development
Finance

All Hazard Emergency Operation Planning Committee:
Hazmat Facility / Transportation
Public Health and Medical
Natural Hazard

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

Print this page.

En Español

This site is speech enabled. Click here to download browsealoud.

Documents on this site are in PDF format. Download Adobe Reader to view them:

Get Adobe Reader

We welcome your suggestions!
Leave feedback.