Application for NAMSA Membership (See Membership Options Below) Please complete this form and send it to NAMSA, then select your electronic payment option. 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. (Not needed if an Insurance Company Employee): State: SSN: (For State CE Credit)

Membership Option (Select One): $240 Full with 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. DATE