TPSA Membership Application

Membership Application

Please complete the form below for TPSA membership.

Schedule of Dues

# of Stores:	Dues:
1	$100
2-4	$125 per store
5-9	$150 per store
10+	$175 per store

You must register each store that you own. TPSA membership is based on a calendar-year from January 1 to December 31.

Trade Name / Company*
Full Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Store Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
E-mail*
Additional Contact / Full Name

First NameLast Name
E-mail
example@example.com
Phone Number

Area CodePhone Number
By agreeing below, I certify that the package stores for which application is made for:

1. Licensed as package stores by the State of Texas, and

2. at least 51% owned by Texas citizens (i.e. 51% owned by individuals who are residentially domiciled in the State of Texas, and who have continuously been residentially domiciled in the State of Texas for the immediatley preceeding year).
I agree with the above statement.*

Click to agree
Payments are processed using any major credit card / debit card.

If you prefer to mail in a check, please download the TPSA Membership Application and send in with payment
Dues payments to TPSA are not deductible as charitable contributions under the Internal Revenue Code. Because a significant poriton of TPSA dues are used to lobby the legislature in issues important to package stores, TPSA dues are generally not deductible under Internal Revenue Code. Consult your tax advisor for complete information.
My Products
prevnext( X )
1 Store$100.00

Quantity
Item subtotal:$0.00

2 - 4 Stores$125.00

Quantity
Item subtotal:$0.00

5 - 9 Stores$150.00

Quantity
Item subtotal:$0.00

10+ Stores$175.00

Quantity
Item subtotal:$0.00

Total $0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Membership Application

Schedule of Dues

Payments are processed using any major credit card / debit card.