PTCB Advocate Employer Program Application and Agreement

* Please note: If you represent a single location that is part of a larger entity, please forward this form and program information to your company’s headquarters.


** This application may only be completed by an authorized director or other management-level representative of the identified applicant company. Otherwise, please forward this form and program information to your employer.

  • Primary Contact Information

  • Alternate Contact Information

  • Company Information