Membership Application | National Association of Professional Allstate Agents

Corporate Membership Application

Membership Dues

Organization Code

If your organization already has an organizational membership, please contact the primary member of your company for the add-on organization password and add it here.This will ensure that your account is linked to your organization's membership. Otherwise, if you are filling out this application as a new member, please leave this field blank.

Your Dues Rate Type is: Vendor Member $500.00

Add-On Password

Attention New Members: you must create a password that will be used by your company representatives in order for their accounts to be added to your organization's membership record. Create this password using a combination of alphanumeric or numeric characters only. This password can be shared with any of your company representatives to create their own individual account tied to your organization. All they need to do is enter the password in the Add-on Organization Password field of the membership application.

Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Middle

Last Name *

Suffix

Title

Informal Name

Company *

Primary Office Address Line 1 *

Primary Office Address Line 2

Primary Office Address Line 3

Primary Office City *

Primary Office State

Primary Office Zip Code *

Country

Website

Company Logo

Phone Number *

Fax Number

CCMail

Include me in Membership Directories *
Yes No

Username/Password Username/Password

Please enter the Username/Password you would like to use to login to this website.

Your Username must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Username *

Password *

Confirm Password *

Payment Details

Comments or Questions

Total Amount Due

Payment Method

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing National Association of Professional Allstate Agents to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting National Association of Professional Allstate Agents, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

Save payment method for future purchases

Enable Automatic Renewals? *

Select "Yes" to enroll in automatic membership renewal. The payment method submitted with this form will be used for your future membership renewals. You can change the automatic renewal setting or saved payment method at any time in either the "Payment Methods" or "Renewal Settings" where you edit your profile.

Yes

Corporate Membership Application

Membership Dues

Contact Information Contact Information

Username/Password Username/Password

Payment Details Payment Details

Contact Information

Payment Details