Membership Application

Legal Business Name

Doing Business as:

Federal ID #

Physical Address

Street Address Address Line 2 City State ZIP Code

Different Shipping Address?

Yes, My Mailing Address is different than my shipping address

Mailing Address

Street Address Address Line 2 City State ZIP Code

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Email

Number of Locations

Location Information*

Supplier	#of Check Out Lanes	Annual Non-Gas Sales Volume	Square Feet	Number of Employees	Number of Pumps

Complete for each of your store's locations

MFDA Programs of Interest to Your Business

"Comp Watch" (Workers Comp Insurance)
Group Health Insurance
Property / Casualty Insurance
Phone Service Program
Coupon Redemption Service

Note:
-Workers Comp insurance is required by law.
-Group Health Insurance is for groups of 50 or more.
-No Minimum coupon count or value.

Owner / Manager Signature*

By typing your name here, you are signifying that all of the information given above is accurate and complete to the best of your knowledge, and you are aware that the information given above will remain confidential, and used only to improve and expedite member services.

MFDA Membership Application

Now you can fill out MFDA forms and applications right here on the website!

Stay informed with Legislative Issues and how they affect your business

Contact MFDA to learn more about membership benefits and programs