ACCOUNT#:
 
P.O. Box 391, Danville, PA 17821
PHONE (800) 597-6017 / FAX (800) 235-2353
 
2009 APPLICATION & AGREEMENT
ALL LINES MUST BE COMPLETED FOR THE APPLICATION TO BE PROCESSED
A NEW APPLICATION MUST BE FILLED OUT AND MAILED EACH YEAR BY ALL ORGANIZATIONS
 
Email Address: 
(*)
Legal Name of Organization: 
(*)
Years of Continuous Operation: 
 
Fields marked as (*) are required.
 
 
First Name: 
(*)
Last Name: 
(*)
Position w/ Org.: 
(*)
Address: 
(*)
Address 2: 
City: 
(*)
State: 
(*)
Zipcode: 
(*)
 
 
Title: 
(*)
Home Phone: 
(*)
Secondary Phone: 
Home Status: 
Email: 
 
 
First Name: 
Last Name: 
Position w/ Org.: 
Address: 
Address 2: 
City: 
State: 
Zipcode: 
 
 
Title: 
Home Phone: 
Secondary Phone: 
Home Status: 
Email: 
 
BILLING INFORMATION
State Tax Exempt #: 
(Not Federal EIN)  
Who Pays Your Bills: 
Billing Name: 
Address: 
Address 2: 
City: 
State: 
Zipcode: 
Email: 
 
SHIPPING ADDRESS
Shipping Name: 
(*)
Address: 
(*)
Address 2: 
City: 
(*)
State: 
(*)
Zipcode: 
(*)
Shipping Information - Choose address location type:
Home
Business
 
 
As of January 1, 2009, did your organization owe any money?: 
If yes, explain: 
 
TREASURER INFORMATION
Name: 
(*)
Address: 
(*)
City: 
(*)
State: 
(*)
Zipcode: 
(*)
 
Home Phone: 
(*)
Secondary Phone: 
Email: 
 
AUTHORIZATION
PLEASE LIST TWO PEOPLE WHO MAY ORDER FOR YOUR ORGANIZATION
 
Name: 
Title: 
Phone: 
Name: 
Title: 
Phone: