MLA Consent Form

Mid-America Lumbermens Association
638 West 39th Street
Kansas City, MO 64111
Ph: 816-561-5323 Fax: 816-561-1249
E-mail: oholcombe@swassn.com

Consent Form - Mid-America Lumbermens Assocition

	URGENT – REPLY REQUESTED Consent Form Mid-America Lumbermens Association
First name
Last name
Title
Store name
Street address
Address (cont.)
City
State
Zip
Phone
FAX(s)
E-mail
	I represent that I am authorized to provide the foregoing consent and understand that by providing my mailing address, email address, telephone number and fax telephone number(s), I consent to receive communications sent by or on behalf of my industry's trade association and affiliated entities - Mid-America Lumbermens Association, MLA Service Corporation, and National Lumber and Building Material Dealers Association (NLBMDA) via regular mail, email, telephone and fax. I also understand that I may revoke this consent with respect to one or more of the entities listed above by notifying such entity in writing of such revocation at any time.
Date

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This page revised 03/06/08