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Exclusivefocus Summer 2012.pdf - National Association of ...

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Confidential NAPAA Membership ApplicationName:______________________________________ Off Ph:_______________________ Cell__________________________Street:________________________________________________ E-Mail:__________________________________________City:________________________________________ State:_____ ZIP:__________Agent since__________(year)Comment?MEMBERSHIP SECTIONRegular (Gold) Membership q Annual: $350 q EFT: $29 /moElite Membership (includes Producer Online Subscription) q Annual: $475 q EFT: $39 /moTo Activate Producer Online Subscription only:User Name _____________ Password _____________PAYMENT SECTIONq 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 ExpressName on account _________________________________________ Amount to be Charged: $__________ (Annual only)Account Number __________________________________________ Expiration date __________ Security code________Address on Card _______________________________________________________________________ZIP____________Signature <strong>of</strong> Cardholder _______________________________________________ Todays Date _____________ (1/12 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 <strong>of</strong> every month.Authorization Signature: _____________________________________________________________Date ____________PLEASE FAX or MAIL APPLICATION TO:<strong>National</strong> <strong>Association</strong> <strong>of</strong> Pr<strong>of</strong>essional Allstate Agents, Inc.P. O. Box 7666, Gulfport, MS 39506-7666Call Toll-free: 877.627.2248 • E-Mail: HQ@napaausa.org • Fax Toll-free: 866.627.2232Please include your generous donation to the NAPAA Action Fund<strong>Summer</strong> 2012 <strong>Exclusivefocus</strong> — 59

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