Corporate Membership Application

Print the following form, complete and mail to:
Highway Safety Center
R & P Building, IUP
Indiana, PA 15705

Name of company:
Contact Person:
Title:
Address:
City:
State:
Zip:
Telephone: (                 )
E-mail:
URL:
Amount Enclosed (payable to ADTSEA):
(refer to the Dues Schedule for details)

Date:
Signature:

Date:

For additional information, please call (724) 357-4051 or fax (724) 357-7595