Welcome Center Brochure Distribution Authorization Form - Pennsylvania On Display

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PENNSYLVANIA ON DISPLAY
Official Brochure Distribution Program for Pennsylvania
Commodity Code #
For Official Use
Welcome Center Brochure Distribution
Authorization Form
(Distribution Not Guaranteed. See Important Information on page 2)
SUPPLIER INFORMATION
Organization
Contact Name
Address
City
State
Zip
Telephone
Fax
E-mail
BROCHURE INFORMATION
see instructions on page 2
Brochure Name / Headline
Business Code
County
Approx. Brochure Size
Initial Shipment Quantity
Brochure Expiration Date
Can remaining or expired brochures
be discarded?
___ Yes
___ No
4x9
___ 8x10
___
DISTRIBUTION LOCATIONS:
Western Pennsylvania
Eastern Pennsylvania
I-90 West Welcome Center (Erie County)
I-95 North Welcome Center (Delaware County)
I-80 East Welcome Center (Mercer County)
I-76 West Welcome Center (Montgomery County)
**
I-70 East Welcome Center (Washington County)
I-78 West Welcome Center (Northampton County)
I-79 North Welcome Center (Greene County)
I-84 West & East Welcome Center (Pike County)
I-81 South Welcome Center (Susquehanna County)
I-80 West Welcome Center (Monroe County)
** Limited space and hours of operation.
Central Pennsylvania
I-70 West Welcome Center (Fulton County)
I-83 North Welcome Center (York County)
I-81 North Welcome Center (Franklin County)
Route 15 South Welcome Center (Tioga County)
AUTHORIZATION
Signature
Print
Title
Date
Revised 08/04/11
Fax completed form to Pennsylvania On Display at 717-653-4808.
1

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