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Website Benefits Order Form

NAME _________________________________________________________________

FIRM/AGENCY_________________________________________________________

ADDRESS ______________________________________________________________

CITY/STATE/ZIP _______________________________________________________

TELEPHONE ________________________ FAX _____________________________

EMAIL ________________________________________________________________

CURRENT MEMBERSHIP CATEGORY:
___ Pennsylvania Chapter of APA individual ___ Pennsylvania Chapter of APA organizational member ___ Pennsylvania Chapter of APA Consultant
___ APA individual ___ Non-Member

I/we would like to order:
Member Non-Member
Single ad for one month $100 $200
Unlimited ads per year $250 $500
Planner profile and link per year $200 $500

Enclosed is my/our check for $______

Please bill our credit card:  Visa  MasterCard
Card Number: _______________________________________________________
Expiration Date: ____________________

Name and address on card if different from above: (please print or type)
______________________________________________________

______________________________________________________

For Office Use Only

	Received	Placed	Expiration
Single Ad
Unlimited Ads/1 year
Planner Profile & Link/1 year

Mail to:
Pennsylvania Chapter of APA
587 James Drive
Harrisburg, PA 17112