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PSH-PAC Contribution Form

The following on-line contribution form is to be used only if credit card payment is provided.

Yes! I would like to contribute to the PSH-PAC.
I understand that my contribution is voluntary and will help support governmental officials who care about and work for my profession.
Contribution Amount $
If you are making a contribution of $200 or more,
please indicate if you would like to receive quarterly invoices:

Contact Information:

First Name:
Middle Name:
Last Name:
Street Address:
Zip Code:
PSHA Member?:
Home Phone:
Work Phone:
PA License:

Payment Method

Credit Card Type:
Credit Card Number:  
  Enter your credit card 16 digit number without hyphens or spaces (example: 1234567891234567)
Expiration Date : Month Year
Questions:  Contact the PSHA Office at 412-366-9858 or

Pennsylvania Speech Language Hearing Association
700 McKnight Park Drive, Suite 708 | Pittsburgh, Pennsylvania 15237
412-366-9858 | 412-366-8804 fx
©2010 Pennsylvania Speech-Language-Hearing Association | All rights reserved.