ASSOCIATIONS COMMUNICATIONS CONSENT FORM

COMMUNICATIONS CONSENT FORM

Effective August 25, 2003, the Federal Communications Commission's (FCC) "Do Not Call, Fax or E-mail" regulations require all businesses to have a signed consent form on file from all entities it sends faxes, e-mails or phone calls to. This electronic form satisfies that requirement. This form must be completed by EVERY individual in your organization who may want or need to receive communications from FlaSEIA and must include EVERY Fax number (office, home, etc.) that may apply.

Fields marked in red are required.

Full Name: Title:

Organization/Company:

Address 1:

Address 2:

City: State: Zip:

E-mail:

Telephone:

Fax:

Additional Fax Number(s):

On behalf of the
Florida Solar Energy Industries Association (FlaSEIA),
Solar Power Political Action Committee (Solar Power PAC),
Solar Energy Industries Association (SEIA)
and all subsidiaries and affiliates of any of the above:

I understand that by providing my mailing address, e-mail address, telephone number, and fax number, I consent to receive communications via regular mail, e-mail, telephone, and/or fax sent by representatives of the organizations listed above.

My preferred method of communication is (please mark in order of preference starting with #1):

e-mail fax mail telephone

I agree that the representatives of the organizations listed above ( MAY or MAY NOT) (please check one response) publish my e-mail address.
I understand that by providing my fax number, I consent to receive faxes sent by representatives of the organizations listed above. I understand that representatives of the organizations listed above ( MAY or MAY NOT) (please check one response) share my fax number with other organizations.

SIGNATURE: (FCC regulations require you to re-type your full name to act as your signature)

I acknowledge the above to be my electronic signature.
(The above box must be checked in order for your consent form to be valid)