VSA Mailing List Order Form

Agreement: The names and address provided are the property of the Society and are supplied for one specific mailing ordered and for no other purpose. After completion of such mailing, this list will be destroyed or erased and will not be used for any other purpose. This list is solely provided for a one-time use only and all guidelines, requirements and restrictions must be observed.

All fields are required

Billing Information
First Name:
Last Name:
Company Name:
List Type:

Additional Specifications
(e.g. which meeting for registrant listing, do not include residents, students, etc.)

A sample of the mailing is required. PDF is the preferred format although we can accept Word documents.
(3 MB maximum size)

I have read, understood, and accepted the agreement.

Credit Card Information
Card Number:
Expiration Date:
Card CVV:
Card Billing ZIP/Postal Code:
Card Holder: