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Pennsylvania Society of Physician Assistants
Mailing Label Order Form
Return with completed usage agreement

The cost is $.10 per label. List requested:

_____ Entire listing
_____ PSPA members only
_____ Regional listing (check all that apply)

_____ Region 1: Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, Westmoreland
_____ Region 2: Blair, Bedford, Cambria, Fulton, Huntington, Somerset
_____ Region 3: Adams, Cumberland, Dauphin, Franklin, Juniata, Lebanon, Mifflin, Perry, York, Lancaster
_____ Region 4: Berks, Bucks, Chester, Delaware, Montgomery, Philadelphia
_____ Region 5: Carbon, Lehigh, Luzerne, Lackawanna, Monroe, Northampton, Pike, Susquehanna, Wayne, Wyoming
_____ Region 6: Bradford, Columbia, Lycoming, Montour, Northumberland, Schuylkill, Snyder, Sullivan, Tioga, Union
_____ Region 7: Cameron, Centre, Clearfield, Clinton, Elk, McKean, Potter, Jefferson
_____ Region 8: Clarion, Crawford, Erie, Forest, Mercer, Venango, Warren

Sort by: _____ Zip _____ Alphabet _____No preference

Ship to:

Signature of Buyer:
________________________________________
Printed Name of Buyer:
________________________________________
Date:
________________________________________
Name of Company/Organization:
________________________________________
Address:
________________________________________
Address:
________________________________________
City, State ZIP:
________________________________________
Phone Number:
________________________________________
Mastercard/Visa Number:
________________________________________
Name as Appears on Card:
________________________________________
Expiration Date:
________________________________________
Amount of Payment Enclosed:
 $_______________________________________

 

PSPA
P.O. Box 128
Greensburg, PA 15601
724-836-4449 (fax)

Return with completed usage agreement
Please note: These are peel and stick laser labels.