MEMBERSHIP APPLICATION

PLEASE TYPE OR PRINT Organization:

Contact Name: Street Address:

Title: City, State & Zip:

Work Phone:

Mobile Phone:

Fax:

Email: Organization Type:

Website: Consulting Energy Engineer Other:_______________ Labor Law Firm

Please also list the email addresses of any of your organizations members who would like to receive our newsletters and updates: Name Email

I agree to join the NJ Energy Coalition. This signature indicates my willingness to use my name and the name of my organization in approved Coalition materials. Signature: ____________________________________________ Date: __________________