Membership Application Form

ACAPMA Distributor Retailer Membership Application
To apply for ACAPMA Distributor Retailer Membership complete this Application. ACAPMA will reach out to commence your membership application.
Business Information
Business Name*
ABN: *
ACN:
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Primary Contact Name*

First NameLast Name
Primary Contact Title*
Phone Number*
Mobile Number*
Email*
example@example.com
Brief Description of the Business
Membership Types
Small Retailer 1-5 sites $860 including GSTMedium Retailer 6-10 sites $2450 including GSTLarge Retail 10+ sites $4900 including GSTSmall Distributor $2450 including GSTMedium Distributor $4900 including GSTLarge Distributor/Retailer $4900 including GST
General Information
Which State or Territory do you operate in?

ACTNSWNTQLDSATASVICWA
Total No of Retail Sites
Total No. of Retail Staff Employed
Total No of Fuel Depots/Warehouses
Total No of Trucks
Total No of Transport Workers (Drivers/Warehouse/Schedulers)
Total No of Admin Staff
Key Contacts
Staff Training Contact Name

First NameLast Name
Title
Contact Number
Email
example@example.com
Accounts Contact Name

First NameLast Name
Accounts Contact Title
Contact Number
Email
example@example.com
Additional Services
ACAPMA offers a range of products that are designed to help members ensure and demonstrate compliance and best practice in retail fuel settings. These optional extras are available to Distributor Members at a discount. To request further information on these programs, and the extensive discounts that areavailable to ACAPMA Members tick the following boxes and the ACAPMA Team will reach out with further information about how these programs could work in your business.
I'd like more information about ACAPMAs online compliance and safety training for fuel retail staff the PCCI'd like more information about ACAPMAs online compliance and safety training for fuel transport staff Delivering Fuel to Retail Sites Employment,Safety and DG ComplianceI'd like more information about ACAPMAs desktop audit of systems and practice that identifies issues and then provides the business with the help, templates and custom documents to address those gaps the Assisted Compliance Audit program
Release & Agreement
To the ACAPMA Board,
I, the undersigned, would like to submit for consideration as an ACAPMA Member this application. I understand that the information provided in this application will be used to determine my eligibility for membership and that the Board will consider this application in the context of the mandate to act in the best interests of all ACAPMA Members
Signed and Submitted by
Name
Signed and Submitted on

MonthDayYear
Date
Should be Empty:

ACAPMA Distributor Retailer Membership Application

Business Information

Membership Types

General Information

Key Contacts

Additional Services

Release & Agreement