SDTA FAX Consent Form

 
1.  Company Name

                                                                                           

 2.  Address                       City              State         Zip

                                                                                             

 3.  Name of Person Authorized to Provide Consent on
      Behalf of the Company

                                                                                              

4.  Title of Person Authorized

                                                                                              

 As the person named in number 3 above, I consent on
behalf of the Company to receive communications and
solicitations via fax on behalf of the South Dakota
Trucking Association.

       Phone Number:                                                       

       E-mail Address:                                                      

       Fax Number:                                                            

 I understand that by providing the information above,
on behalf of the Company, I am authorized to and
hereby consent for the Company to receive faxes
from SDTA.  I also acknowledge that SDTA
is relying on my representations on this Consent form
regarding authority to bind the Company.  I agree
that to notify SDTA, if consent is revoked, and
understand that SDTA is entitled to rely on this
Consent, unless revoked.

 

 Signature:                                              Date:                      

 

 Please return this form by FAXING OR
mailing as soon as possible to:

South Dakota TRUCKING Association
PO Box 89008
Sioux Falls, SD 57109-9008
Fax: (605) 334-1938