General Membership Application

Print the following form, complete and mail to:
Highway Safety Center
R & P Building, IUP
Indiana, PA 15705

Name:
Title:
Address:
City:
State:
Zip:

Work phone:
Home phone:
Fax:
Email:

Renewal __________

New __________

Membership Type ______________________________________

(refer to the Dues Schedule for complete descriptions of the different types of memberships)

Amount Enclosed (payable to ADTSEA):

Date:

Signature:

Date:

For additional information, please call (724) 357-4051 or fax (724) 357-7595