Membership • Smoke Free PA

Company Name*

EIN #

Contact Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone*

Mobile Phone

FAX

Email*

Business Description

The following categories best describe my business.

Check all that apply

Retailer
Manufacturer
Wholesaler

Membership Options

I have read the membership descriptions on the PSFA Membership Options form. Subject to the By-laws of the Association, please enroll my company as a Member of the Pennsylvania Smoke Free Association that I have indicated below. I understand that our dues or other payment applies to the current calendar year. I have indicated the appropriate payment below:

Industry Member - Recognized as members, with right to elect Board members and serve on the Board.
Affiliate Member - Recognized as members, but shall not vote and shall not be eligible for the Board.
Check here if you would like this to be a reoccurring transaction

Date*

Comments

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PSFA – Membership Application

Business Description

Membership Options