!
Q u a n t i t y P r i c e * T o t a l
Additional Category $20
Company Representative Contact Information $50
Company Description $25
Company Logo and Social Media Links $50
To ta l A mo unt
D
i s c oun t (Silver – 10%, Gold -15%, Platinum – 20%)
G r a n d T o t a l A m o u nt
!
Co n t act In f o r m ati on
Date: _____________________________ Member Number: ________________________________
Company Name: ___________________________________________________________________________
Contact Name: _____________________________________________________________________________
Contact Email: _____________________________________________________________________________
Contact Phone: ____________________________________________________________________________
!
P aym e n t In f o rm at io n
! Visa! ! MasterCard! ! American Express!
Cardholder Signature: _______________________________________________________________________
Cardholder Name (Please Print): ______________________________________________________________
Card Number: ______________________________________________________________________________
Expiration Date: _______________________ Security Code: ___________________________________
*Per Year
2626 East 82
nd
Street – Suite 175 | Bloomington, MN 55425
Phone: (952) 854-8300 | Fax: (952) 854-7560 | Email: info@psai.org | www.psai.org
Online Supplier Directory Order Form
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