Name of Organization:_________________________________________

Complete Business Address: ___________________________________

___________________________________________________________

City: __________________________________________State: _______

Zip: _______________________________

Telephone Number: ____________________________________________

Fax Number: _________________________________________________

E-Mail: ______________________________________________________

Name of designated Representative to PEG
(fill in contact information if different than above):

Representative's Name: __________________________________________

Complete Business Address:______________________________________

Telephone Number: _____________________________________________

Fax Number: __________________________________________________

E-Mail: _______________________________________________________

Choose One Interest Category:

Print Name _____________________________________________________
 
Signature ______________________________________________________

Date __________________________________________________________