Office of Emergency Management

About LEPC Membership Form

LOCAL EMERGENCY PLANNING COMMITTEE
2007 Executive Board

Todd Gregory - Chair
Tim Zagorski - Vice Chair
Ron Camnunez - Secretary
Carey Latesa - Treasurer
Delia Cervantes - OEM Representative

MEMBERSHIP APPLICATION July 1, 2007 - June 30, 2008

All fields are required to be filled out. If a field does not apply, please put NA.

MEMBERSHIP TYPE
NEW RENEWAL

VOTING RIGHTS
MEMBER WITHOUT VOTING RIGHTS
MEMBER WITH VOTING RIGHTS - AMOUNT DUE $20.00 (per year)

Name:
Title:
Agency:
Address:
City/State/Zip:
Work Phone:
Home Phone:
FAX
Pager
Mobile:
Email:

Why do you want to be a member of the LEPC? (Optional)

What would you be able to contribute to the LEPC? (Optional)

Which Sub-committee(s) would you like to serve on?
Committee Awareness / Education / Membership
Exercise / Planning / Development
Finance

All Hazard Emergency Operation Planning Committee:
Hazmat Facility / Transportation
Public Health and Medical
Natural Hazard

Agency Affiliation (Please check one):

Municipal/State Government	Local Elected Official
Law Enforcement	Emergency Management
Fire Services	EMS/Medical Response
Health Professional	Local Environment
Hospital/Clinic	Transportation
Broadcast/Print Media	Community Agency
Facility Operator subject to EPCRA	National Weather Service
Military	Federal Facility
Correctional Facility	Public Schools
University/College	Private Citizen
Other

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