Application  for NAMSA Membership (See  Membership Options Below) Mail  To:  NAMSA, PO Box 4459,  Helena, MT 59604. and 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 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. SIGNATURE  ____________________________ DATE  _______________ (For  electronic application and to pay by credit card,  go to On-Line  Application.)