Application | California Fuels & Convenience Alliance

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Company Information (to be displayed online)

Company Name

Recommended By

Address 1

Address 2

City

State

Zip

Phone

Fax

Website

Main Contact

First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

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Membership Investment

Membership Type

Primary Directory Category

Additional Directory Categories

Select additional directory categories below by holding the "CTRL" key

Fuel Sales

Your Membership Dues are as follows:

Less than 10 million gallons - $1,200
10-15 million gallons - $3,500
15-25 million gallons - $6,500
25-100 million gallons - $7,500
100-200 million gallons - $8,500
Greater than 200 million gallons - $10,000

Please enter your gallonage based on your annual fuel sales; all fuel types included.

Number of Gallons

Retail Dues

Your Membership Dues are as follows:

Less than 5 stores - $100
5-10 stores - $200
Each store over 10 is an additional $50 per store

Number of Stores

Your membership dues will be $1,000 for 1-10 trucks, $1,500 for 11-20 trucks, or $2,000 for over 20 trucks.

Number of Trucks

Annual Dues (charged to card)

Contribution (charged to card)

Contributions

Government Relations

Additional** contribution to CIOMPAC (ID# 760982)

10% of membership dues will be contributed to the CIOMA Political Action Committee (ID#760982). Contributions to CIOMPAC are voluntary and not deductible as charitable contributions for federal or state income tax purposes. Individual contributions are limited to $7,300 per calendar year.

Check this box to opt-out of voluntary contributions.

Total

The contents of this box are for testing purposes. This box will be removed when the form goes live.

Associate Membership

Refiner

Broker

Number of Full Time Employees

Number of Part Time Employees

Number of Locations

Millions in Assets

Annual Membership Investment

Additional Items

Additional Categories Cost

One-Time Application Fee

Tax

Full-Time Employees

Part-Time Employees

Stores

Restaurant Seats

Additional Associates

Additional Associates Cost

Additional Locations

Additional Locations Cost

Assets

Assets Cost

Additional Categories

Number Of Additional Categories

Additional Categories Cost

Additional Item 1 Cost

Additional Item 2 Cost

Additional Item 3 Cost

Additional Item 4 Cost

Additional Item 5 Cost

Additional Item 6 Cost

Additional Item 7 Cost

Additional Item 8 Cost

Additional Item 9 Cost

Additional Item 10 Cost

Contribution Opt Out

Revenue Item

Tax (charged to card)

Fee (charged to card)

Temp Value For DropDown 1

MembershipType

Additional Item 4

Additional Item 5

Additional Item 6

Additional Item 7

Additional Item 8

Additional Item 9

Additional Item 10

Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Additional Information

Dues Payments to CIOMA may be deductible as ordinary and necessary business expenses to the extent they are not used for specific state or federal lobbying expenditures (IRC 162). CIOMA estimates that 50 percent of your membership dues will be used for lobbying expenditures and are not deductible for federal or state income tax purposes (CIOMA federal Tax ID # 23-7108799).

Credit Card Information

Credit Card Type MastercardVisaAmex

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