Address *

Address for the member organization

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Select Level of Membership Participation *

Eligible members may be: 1. Permitted Dischargers: Counties, municipalities, special districts, industrial, or other permitted dischargers with a wastewater treatment plant in the Upper Clear Creek Basin. 2. Governmental Entities with Land Use/Water Quality Control Authority: Governmental entities having legislative authority to enact and enforce water quality control or land use regulations or to establish erosion control measures in the Upper Clear Creek Basin. 3. Cooperating Partners (non-voting): Non-profit organizations, other public agencies, or other entities who share a common interest in protection or restoration of the Upper Clear Creek Basin and who wish to partner with UCCWA in the protection of water quality. Non-Voting-Membership entity with interest in protection of water quality in the watershed and are currently or have been involved in implementing water quality activities in the watershed. The annual fee for non-voting membership is $275.00. • May not vote on association business or hold elective office.

Voting

Non-Voting

Inactive

Primary Representative Name *

Name of primary representative for your organization

First Name

Last Name

Phone *

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Alternate Representative Name

As an option to naming a specific Alternate Representative, a membership entity may instead designate a staff alternate which would allow any appropriate staff member to attend meetings and vote when the primary representative is not available. Please consider that UCCWA meetings are held on the second Thursday of each month from 8:30am to approximately 10:30am. Please choose a representative that will be available at this time.

First Name

Last Name

Alternative Representative Phone

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