Pennsylvania Retailers' Association

Fill out and print the form below, or click here to download the application in .PDF format to fill out and return.

Company/Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Title:

Phone:

Ext:

Fax:

Type of Business:

Website:

Email:

Total Number of Stores:

Total Number of Stores in PA:

Number of Employees:

Full Time

Part Time

Annual Sales Volume:

Average Ticket Amount:

Credit Card Volume:

Discount Rate:

Transaction Fees:

Workers' Comp. Ins. Carrier:

Exp. Date :

I (We) accept your invitation and submit this application for membership in the Pennsylvania Retailers' Association. I (We) agree to cooperate with the association in promoting its objectives on behalf of retailers, their affiliates and the retailing industry.

Signature ____________________________ Date ____________

Investment Dues Options: *Please call 1-800-727-3824 for current Investment options.
Card number / Select card type below.		Name on card		Expir.

Visa	Mastercard	American Express	Discover	CIC Code

-OR-
Check	in the amount of ____________ for annual dues
Would you like to be added to our mailing list?				Yes No
Print form and mail to:		Pennsylvania Retailers' Association 224 Pine Street Harrisburg, PA 17101
Or fax your application to: Toll Free: 717-236-1234 *For questions, call the PA Retailer Membership Department at 1-800-727-3824*