Member Information Form Please give the legal name, address and phone number of your company. This DOES NOT have to be where you will be receiving locate requests.Company Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Type of Underground Facilities: (Select all that apply) *Cable/TVGasElectricWaterSewerPipelineTraffic LightTelecommunicationsWindOtherOtherPrimary Contact Information*Will be listed on ticket for excavator questionsName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Billing InformationSame as PrimaryName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Mapping InformationSame as PrimaryName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Receiving company contact information/site receiver informationHow do you want to receive requests:Email (preferred method)FTPLocator Ticket Management (LTM)Email Address: *FTP Credentials:FTP Site: *FTP Login: *FTP Password: *Contact Name:Contact Phone:Company Name:Mailing Address:Please list all counties you have buried facilities in: *Completed by *Date *CDC CodeSignatureStart signing your signature hereYour browser does not support e-Signature field.Submit
