PA TruckPAC Authorization Form

This Authorization allows PMTA member companies to grant this authorization for up to three years by signing on behalf of the corporate member next to each year that the authorization is granted.

By signing this authorization, I am verifying that, to the best of my knowledge and belief, that:
1. I am an authorized representative of the company indicated below.
2. The company indicated below is a member of PMTA.

3. I am authorized to execute this authorization on behalf of the company.

And on behalf of my company I am authorizing PA TruckPAC to solicit the restricted class of employees of the company, and as such may be expanded, for the calendar years listed below.

Fields marked with an * are required.

First Name *

Last Name *

Title *

Organization *

City *

City where you live.

State *

State that you live in.

Postal Code *

Your personal zip code.

Email *

Phone

Are you a PMTA Member? *

Yes

Duration *

Please confirm how many years you authorize:

1 full year from time of submission

3 full years from time of submission

For the duration of my employment with the company listed on this form

Signature *

Please type your first and last name exactly as they appear on this form. By typing your full name as it appears on this form, you are providing your official signature and authorization to solicit on behalf of the PA TruckPAC.

Please verify that you have checked the “I'm not a robot” checkbox.