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.)