LLSSA Membership Application

Company Name:

Physical Address (Street, Ste, City, State & Zip):

Company Mailing Address:

Company Phone Number:

Company Fax Number:

Company Web Site Address:

Name of Primary Voting Representative:

Company Email: (You will receive Meeting notices, Education Info, Invoices etc)

Voting Representative Email:

List of Amount of Dues per Membership Category

Regular Member: 1-5 Employees = $668.00

Regular Member: 6-10 Employees = $830.00

Regular Member: 11-15 Employees = $960.00

Regular Member: 16-25 Employees = $1,155.00

Regular Member: 26-50 Employees = $1,773.00

Regular Member: 51-100 Employees = $2,163.00

Regular Member: 101-150 Employees = $2,943.00

Regular Member: 151 + Employees = $3,723.00

LLSSA National Member - $440.00

LLSSA Associate: $150.00

LLSSA Affiliate Membership: $150.00

LLSSA Related Industry Membership: $340.00

LLSSA Public Safety: $50.00

LLSSA Alumni Membership: $100.00

License Endorsements: (check all that apply)

Membership Information:

Month/Year Founded:

Number of Locations:

Number of Employees:

Based on the Membership type and number of employees (if applicable), my membership dues for one year will cost:

Type of Membership:

Membership Renewal and Lobbyist Assessment fee will be invoiced annually. Upon approval from the Board of Directors of LLSSA and one full year membership has been received, your company becomes eligible for all rights under your membership classification according to the LLSSA/ESA By-Laws. It is the policy of LLSSA to not accept the membership request of any company that has administrative action pending with the Office of State Fire Marshal until the action has been resolved.

Name of the Person Completing this Application:

Phone Number:

Your Email Address:

After you hit join, an email will be sent to your email address for verification.