Membership Registration Form
Notification E-mail address must be company or agency affiliated.
No personal E-mail addresses.
Please complete the form below, no partial applications accepted.

Contact Person and Notification Information:  (* required)
Full Name*  (Last Name, First Name) Title* Company/Agency Name* Address Address (additional) City*   County*  -Select-AitkinAnokaBeckerBeltramiBentonBig StoneBlue EarthBrownCarltonCarverCassChippewaChisagoClayClearwaterCookCottonwoodCrow WingDakotaDodgeDouglasFaribaultFillmoreFreebornGoodhueGrantHennepinHoustonHubbardIsantiItascaJacksonKanabecKandiyohiKittsonKoochichingLac qui ParleLakeLake of the WoodsLe SueurLincolnLyonMcLeodMahnomenMarshallMartinMeekerMille LacsMorrisonMowerMurrayNicolletNoblesNormanOlmstedOtter TailPenningtonPinePipestonePolkPopeRamseyRed LakeRedwoodRenvilleRiceRockRoseauSt. LouisScottSherburneSibleyStearnsSteeleStevensSwiftToddTraverseWabashaWadenaWasecaWashingtonWatonwanWilkinWinonaWrightYellow MedicineOther State/Province -Select-AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNorthwest TerritoriesNova ScotiaOhioOklahomaOntarioOregonPennsylvaniaPuerto RicoQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Territory-No State-   Zip Is this your home office or is it a branch office? Home Branch Do you have more than one Eden Prarie location? Yes No (if Yes please state below)	Notification E-mail Address* Confirm Notification E-mail Address Daytime Phone* (include area code) Mobile Phone (if available) (include area code) Mobile Provider Select your mobile provider...AT&T WirelessCingular WirelessNextelSprint PCSSuncomT-MobileUS CellularVerizon WirelessVirgin MobileAlltelCell 2000Midwest CellularMTS CanadianQwestRural Cellular CorporationUnicell Can receive text messages Mobile Email Address 24 hr Emergency Number (if available) (include area code) Access Members Only Area Create password to enter members only area*

Supervisor Contact Information:
Immediate Supervisor* Title*	Daytime Phone* E-mail Address (if available)

Description of Facility and Nature of Business*

(e.g. Second largest petrochemical facility with refining capacity of xxx barrels per day)

GPS Coordinates (if available)

Do you have the ability to donate resources or items in case of emergency?

(list items or services below)

SIC Code:

SIC Code  (click here to find your SIC Code)

Do you grant permission for the City to list your business as a member of PER on the website, in written materials or other public documents?* Yes No

Providing false or misleading information is a violation of Federal Law and may be
subject to prosecution under Title 18 USC 1001.

All information is subject to review and verification.
Completion of this application is no guarantee of inclusion in PER.