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PSPA Mailing List
Usage Agreement

The undersigned agrees to adhere to the following provisions concerning the use of names and addresses furnished on labels which the undersigned has ordered:

  1. The names provided are confidential and proprietary information of the PSPA and may not be disclosed to any third party without express written permission of PSPA;
  2. The names provided will be used for one-time mailing use only;
  3. The names will be used only for the specific mailing for which they were ordered and for no other purpose, unless specifically authorized in writing;
  4. The names will not be copied for use as a mailing list or otherwise;
  5. The names will be used within a reasonable time after receipt in order to retain the advantages of list accuracy;
  6. The PSPA is not required to provide forwarding address for undeliverable mail;
  7. The use of the list for telemarketing purposes is strictly prohibited;
  8. The buyer agrees to furnish PSPA with a copy or sample of printed material, literature, and advertising material made in accordance with this agreement.

This agreement shall be binding upon the undersigned, its principals and its agencies, agents, servants, licensees, subcontractors, affiliates, associates and assignees.

Indicate if you wish the entire list or a portion (members only, restricted zip code, or restricted county) and also indicate if you prefer zip code order or alphabetical order: ____________________________________________________________

_____________________________________________________________________________________________

Nature of the specific mailing for which these labels were orders: ____________________________________________

 

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:
________________________________________

 

Pennsylvania Society of Physician Assistants
P.O. Box 128
Greensburg, PA 15601
724-836-6411
724-836-4449 (fax)