TPTA MAILING LABEL ORDER FORM
 
Please check or fill in ALL of the appropriate spaces in each section:
 
COST: Each label run is $70.00 plus $5.00 shipping & handling for members or $90.00 plus $5.00 shipping & handling for non-members.
 
SEND LABELS TO:
 
Name: __________________________________________________________________
 
Company: _______________________________________________________________
 
Address: ________________________________________________________________
              
               ________________________________________________________________
 
 
SEQUENCE: Numeric Zip_____    Alphabetic_____
 
GEOGRAPHIC AREA DESIRED:           Full State_____
                                                           
East Districts: Chattanooga _____ Knoxville___ Tri-Cities___  
West Districts:            Memphis___ Jackson____
                                    Middle District: Nashville____
 
CLASSIFICATION: (Categories are PTs, PTAs, PT students, PTA students)
 
______ All (includes full state current members-all categories – approx. 1700 addresses)
 
PTs only___ PTAs only___ Students only___
 
Credit Card #: ___________________________________Exp:_________
Name on Credit Card:____________________________Visa/MC Only
 
GUIDELINES FOR USAGE OF LABELS
 
1.                  Please submit a copy of materials that will be mailed using these labels.
2.                  Please do not make a reference to TPTA in your mailing piece unless your course has been approved for continuing education by TPTA.
 
PLEASE RETURN ORDER FORM, PAYMENT AND SAMPLE TO:
            Tennessee Physical Therapy Association
            4205 Hillsboro Rd, Ste 317
            Nashville, TN   37215
Or FAX to:  615-297-5852
If there are any questions, contact the TPTA office at 615-269-5312 or by email at tpta@tptatn.com.
 
 
All advertisements must conform to the ethical standards and policies of the American Physical Therapy Association (APTA) and the Tennessee Physical Therapy Association (TPTA). The TPTA reserves the right to decline any advertisement submitted for publication on the TPTA website, in Volunteer Voice, or in any other TPTA publication, production, or presentation.
 
 
 
 
PLEASE NOTE: 
APTA is opposed, as a matter of health care policy, to arrangements under which sources of referral (including physicians) stand to profit from referring patients for physical therapy.  The policy, adopted by the House of Delegates, states: The American Physical Therapy Association opposes... participation in services that is in any way linked to the financial gain of the referral source." Financial considerations in Practice (HOD 06-99-13-17).
 
Because of this policy, TPTA does not provide mailing labels to a practice if any physician has a financial interest in the practice and refers patients to an employed physical therapist or to a physical therapist who supervises an employed physical therapist assistant.  To complete your submission, you must make the following certification by checking the "I agree" box below:
 
"I certify that no referral source (including any referring physician) has a financial interest in the practice that has the position that is the subject of this advertisement."
 
  _______ I AGREE
 
­­­________­­­________________SIGNATURE _____________ DATE
 
 
 
 
 
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