APDA PAC PRIOR APPROVAL FORM

I know APDA plays an important role in representing the portable diagnostic industry in the political arena. I understand that federal law requires APDA PAC to obtain written permission in order to share information and solicit contributions from member companies' executive and management personnel.

I also understand that signing this form does not obligate me or anyone else to make a contribution. A member company can authorize only one trade association per calendar year to solicit its employees.

Submit this form to give APDA permission to communicate with you about PAC activities.

* I certify that I am

PERMISSION TO SOLICIT

On behalf of my company, I authorize APDA PAC to solicit personal and voluntary contributions.

* You have permission to solicit me for APDA PAC contributions during the years indicated below.
* You have permission to solicit executive and management personnel for APDA PAC contributions during the years indicated below.
* AUTHORIZED SIGNATURE - To sign type your full name
0/50
Email Address
0/50
Title of Authorized Signer
0/50
* Company Name
0/50
Company Contact Name (if different than authorized signer above)
0/50

Thank you for supporting APDA and the Industry by completing this form.

If you have questions or comments please call 888-892-2732 ext 105 or email communications@apdahealth.com