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