Membership Application

Use the form below to become a member of UULLA and start taking advantage of our benefits and support system within our industry!
To submit an application, fill out this form completely; print the form by right-clicking anywhere on the page and selecting Printer or use the File/Print menu function in your browser. Then send this form along with a check for $350 to the address below.

Bob Baamonde - Treasurer
c/o C & C Leak Detection
69401 16th Section Road
Pearl River, LA 70452

 

[ ] General Membership  ($350)
[ ] Vendor/Manufacturer Membership ($350)

Please provide the following information:

Company Name* ____________________________________________________________
Contact Name* ____________________________________________________________
Street Address ____________________________________________________________
Address (cont.) ____________________________________________________________
City ___________________________________
State/Province ___________________________________
Zip/Postal Code ___________________________________
Country ___________________________________
Main Office Phone ___________________________________
Contact Phone* ___________________________________
FAX ___________________________________
E-mail* ___________________________________
Website Address ___________________________________
Geographic Service
Coverage Area

____________________________________________________________

____________________________________________________________

____________________________________________________________
Description of Services
Your Company Provides:

____________________________________________________________

____________________________________________________________

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