Member Information Form Back to the Facility Operator page. Please give the legal name, address and phone number of your company. This DOES NOT have to be where you will be receiving locate requests.Company Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Type of Underground Facilities: (Select all that apply) *Cable/TVGasElectricWaterSewerPipelineTraffic LightTelecommunicationsWindOtherOtherPrimary Contact InformationName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Billing InformationSame as PrimaryName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Mapping InformationSame as PrimaryName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Design Request ContactSame as PrimaryName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *Receiving company contact information/site receiver informationHow do you want to receive requests:Email (preferred method)FTPLocator Ticket Management (LTM)Email Address: *FTP Credentials:FTP Site: *FTP Login: *FTP Password: *Contact Name:Contact Phone:Company Name:Mailing Address:Please list all counties you have buried facilities in: *Completed by *Date *CDC CodeSignatureStart signing your signature hereYour browser does not support e-Signature field.4+4= *Please answer the following math problem prior to submitting your inquiry. This is a security feature to prevent spam submissions. SubmitPlease do not fill in this field.