Application for NAMSA Membership
(See Membership Options Below)

Mail To:   NAMSA, PO Box 4459, Helena, MT 59604.  Submit application fee.

 (Print this Mail-In Application, complete it and send it with your check or money order to the address above.
For electronic application and to pay by credit card, go to On-Line Application)

NAME    _________________________________   

AGENCY/COMPANY NAME
      ___________________________________________

DAY PHONE NUMBER  _________________________

FAX NUMBER  _______________________________

E-MAIL ADDRESS (IF APPLICABLE—PRINT CAREFULLY)
     ___________________________________________

MAILING ADDRESS ____________________________

SHIPPING (STREET NEEDED)
     ___________________________________________
CITY, STATE, ZIP

_______________________, ______, _______________

Resident Insurance Producer’s License No.:

____________________
State:

_____________________
(Not needed if an Insurance Company Employee)
SSN: (For State CE Credit)

_______- ____- ________

Membership Option (Select One):
( ) $240 Full, Printed Materials   ( ) $210 Full, On-Line   ( ) $100 Associate

I understand that membership in NAMSA does not allow me to associate myself in any way with Medicare, or any other government entity, nor am I allowed to hold myself out as a representative of such.  I understand that, should I not satisfactorily complete both examinations within three months of the date of receipt of course materials, I will be allowed an additional thirty days in which to satisfactorily complete both examinations.
If I do not satisfactorily complete both examinations there will be a $25.00 refund.

SIGNATURE ____________________________  DATE _______________