Exclusivefocus Spring 2013 - National Association of Professional ...

Confidential NAPAA Membership Application
Name:______________________________________ Off Ph:_______________________ Cell__________________________
Street:________________________________________________ E-Mail:__________________________________________
City:________________________________________ State:_____ ZIP:__________
Agent since__________(year) Comments
MEMBERSHIP SECTION
Regular (Gold) Membership q Annual: $350 q EFT: $29 /mo
PAYMENT SECTION
q CHECK – Annual: Please make payable to NAPAA.
q CREDIT CARD – Annual: I authorize this amount to be charged to my credit card.
(Please complete the information below)
Card type: q VISA q MasterCard q Discover q American Express
Name on account _________________________________________ Amount to be Charged: $__________ (Annual only)
Account Number __________________________________________ Expiration date __________ Security code________
Address on Card _______________________________________________________________________
ZIP____________
Signature of Cardholder ______________________________________________ Todays Date _____________ (12/12 EF)
q EFT (PAM) - Monthly (attach or fax voided check)
I understand that the amount stated above will be deducted from my checking account every month until instructed otherwise.
I have enclosed a voided check and understand that the withdrawals will occur on or about the 20 th of every month.
Authorization Signature: _____________________________________________________________
Date ____________
PLEASE FAX or MAIL APPLICATION TO:
National Association of Professional Allstate Agents, Inc.
P. O. Box 7666, Gulfport, MS 39506-7666
Call Toll-free: 877.627.2248 • E-Mail: HQ@napaausa.org • Fax Toll-free: 866.627.2232
Please consider including a generous donation to the NAPAA Action Fund!
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