Reinstatement Form – Publications

Reinstatement - Publications

Publication Name*
Publication Owner/Organization
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Office Phone (for directory)*
Publication Email (for directory)*
Website
Must include http:// at the beginning.
Primary Contact Person*
First Last
Primary Contact Title
Primary Contact Phone*
Primary Contact Email*
Editor
First Last
Editor's Email
Contest Category*
Please check the category option for your publication.
Frequency of Publication*
Digital-only publications may enter N/A.
Circulation per issue (print)*
Digital-only members should enter N/A.
Monthly Web Traffic (digital)*
This should be an estimate of the number of MONTHLY visitors to your website or blog. If no website, enter 0. If unknown, enter unknown. e-Newsletters should enter the number of subscribers/recipients for a single e-blast.
Do you accept freelance material?*
Do you publish reviews?*
Do you carry advertising?*
What is your subscription rate?
Write a brief description of your publication.*
50 word limit.
Staff Names*
Include names, titles and email addresses for each staff member who specifically works on your publication. Please include all editorial, design and production staff (but not freelancers). Click the plus sign to add more lines.
Name Title Email Address
Remote Staff Addresses
If you or any of your publication staff listed above works remotely away from the publication headquarters, please enter their name and mailing address here in order for EPA to mail Liaison directly to them. Click the plus sign to add more lines.
Name Address City State Zip
Membership Dues Payment
Online submissions must include credit card payment. Thank you.
Annual Membership Dues*
Choose your dues level based on circulation or other applicable category.
Digital Add-on Option
Optional: For an additional $84 in annual dues, print publications may upgrade to a dual membership to include their website as well, making online content eligible for the annual contest.
- Yes - Digital Add-on
- No
Promo Code
If you have a promo code, enter here.
Convention Discount
Introductory Discount
Total
$0.00
Comments (optional)
Include here anything you want to tell us not otherwise addressed on the form.
Your submission of this application is certification that you qualify to be a member and that you subscribe to EPA’s Doctrinal Statement, as well as EPA's Code of Ethics.
Do you agree with EPA's Doctrinal Statement?*
- Yes
- No
Do you agree with EPA's Code of Ethics?*
- Yes
- No
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address for Credit Card
Street Address City State / Province / Region ZIP / Postal Code Country
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Reinstatement - Publications

Membership Dues Payment