SOUTH JERSEY TRAFFIC SAFETY ALLIANCE

Buckle Up Stencil Program
Participating Form

 Organization Name and Address:

Contact Persons Name and Phone Number:

Address of locations to be painted                                            number of exits

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I hereby authorize the South Jersey Traffic Safety Alliance to make whatever arrangements are necessary to paint the buckle up stencil on the locations listed above.

Authorizing Signature:  _______________________________     Date: ______________

Printed Name and Title:  ___________________________________________________

Painting will be completed within 30 days of submission.

                  Serving Atlantic, Cape May, Cumberland and Salem Counties
1173 E. Landis Ave, Vineland, NJ  08360
Tel:   856-794-1941     Fax:  856-794-2549     Website:  SJTSA.ORG