First Name * :

Last Name * :

Email * :          

Company/ Organization * :         

Job Title (i.e. Fleet Manager) :

Address * :     

Address 2 :     

City * :     

State * :     

Zip * :     

Phone * :         

Web address * :

Additional Names and emails of individuals to receive Clean Cities emails and invitations :

Comments :

Survey questions (optional)

1) Number of alternative fuel and technology vehicles :     

2) Type of alternative fuel and technology vehicles :           

3) Your interests :

Biodiesel

Electric / Plug in hybrid electric vehicles

Ethanol

Alternative technology/efficiency/reduced energy use

Compressed natural gas

Liquid propane gas

Other :

Membership Options:

Regular Member: $250/yr

Non-Profit Member: $100/yr

Student/Individual Member: $50/yr

Colorado Clean Cities Member: $500/yr (includes Annual membership to Northern Colorado, Denver Metro and Southern Colorado Coalitions, with NCCC as your primary coalition unless you are in a different region).

To make payment, please click the Continue button to preview your listing and confirm that all data is accurate. You will have the option to submit payment from this page. If you would prefer to pay by check, please print this form and mail your check (made payable to Northern Colorado Clean Cities) to:

City of Ft. Collins, Attn: Tracey Ochsner, Northern Colorado Clean Cities, PO Box 580, Ft Collins, CO 80522