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CITIZENS FOR COAL
2011 Membership Form

Name of Applicant:_______________________________________________________

E-Mail Address: _________________________________________________________

Address________________________________ City ________________ Zip______________

Phone #: _____________________________ Fax #: _________________________________

Name of Company: _____________________________________________________________

Address: _______________________________ City ________________ Zip ______________

State: _________________ Co. Phone#: _____________________ Fax: _______________

Incorporated___________________ Partnership ______________ Other _______________

Owners or Officers Names: 1________________________ 2_________________________

3________________________ 4_________________________

Tax ID # _____________________________________ Number of Employees ____________

Membership Dues $10.00 Annually -- Make Check Payable to: (Citizens for Coal.)

_____________________________________________ ________/_______/_______

Applicants Signature Date

Mail to:

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