ALABAMA WATER POLLUTION CONTROL ASSOCIATION
INDIVIDUAL MEMBERSHIP APPLICATION

INDIVIDUAL INFORMATION:
Name:____________________________
Home Mailing Address(required):___________________________________
City:________________ County:___________________ State:_____ Zip:_______
Home Phone #:_______________________
Work Phone#:______________________
Email Address (required):___________________________
Job Title:__________________________

PLEASE CIRCLE YOUR CERTIFICATION GRADE:
WATER: I II III IV - WASTEWATER: I II III IV

METHOD OF PAYMENT:
Enclosed is: Check_____ Money Order_____ Cash_____ in the amount of $40.00
(Please make checks or money orders payable to AWPCA)

Signature of Applicant:_________________________________________________