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The DMA Safe Harbor Program
Guide for Businesses

COMPANY CONTACT COVER SHEET

Please submit the following information to the DMA as a condition of membership in the DMA Safe Harbor Program. The DMA Corporate Responsibility staff looks forward to working with you throughout the process. If you have any questions, please feel free to contact our staff by:

Phone: 202.955.5030 ext. 2436
Fax: 202.955.0085
Email:
safeharbor@the-dma.org

------------------------------------------------------------------------------------------------------------

Company Name: ________________________________________________________

Contact Name: __________________________________________________________

Title: __________________________________________________________________

Address: _______________________________________________________________

City: __________________________________________________________________

State: __________________________________________________________________

Zip: ___________________________________________________________________

Telephone: _____________________________________________________________

Fax: ___________________________________________________________________

Email: _________________________________________________________________

Website: ______________________________________________________________

Company Industry Sector(s):
(please choose all that apply)

financial services
health care services
computer services
manufacturing
retailing
direct marketing services
nonprofit services
telecommunication services
transportation/aviation services
tourism
other (please specify) ________________________________________________
other (please specify) ________________________________________________
n/a

Your published Safe Harbor Privacy Policy is located at:
URL address: ____________________________________________________________

Your company receives personal data from the following EU countries:
Austria
Belgium
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Luxembourg
Netherlands
Portugal
Spain
Sweden
United Kingdom

Please submit this form along with the following documents:

A copy of your safe harbor privacy policy;
DMA Safe Harbor Contract; and
Annual Safe Harbor Contract fee:

$1,000 fee, for companies with annual revenue over $50,000,000
$500 fee, for companies with annual revenue between $5,000,000 and $50,000,000
$250 fee, for companies with annual revenue under $5,000,000

Please send to:

Direct Marketing Association
Attn: Safe Harbor Program
1615 L Street NW, Suite 1100
Washington, DC 20036

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