Exclusivefocus - National Association of Professional Allstate Agents ...

NAPAA Membership Applicationand/or Action Fund DonationName:______________________________________ Off Ph:_______________________ Fax__________________________Street:________________________________________________ E-Mail:__________________________________________City:________________________________________ State:_____ ZIP:__________ Home Ph: _______________________Is this address your ❑ Home or ❑ Office?Status: ❑ Active Agent ❑ EFS Agent ❑ Staff ❑ Other (please explain)____________________________________Date: _____________ Years with Allstate________ Office Zip Code (If using home address) __________________Referred by: _______________________________(name of person or publication that inspired your membership)MEMBERSHIP SECTION - (CONFIDENTIAL)Includes:• Free Insurance Leads from the NAPAA Website ❑ Annual $350/yr• Member-to-Member Transfer-in Referrals• Timely Communications, including a weekly newsletter ❑ EFT $29/mo• Comprehensive Resource Center• Resources for Buying and Selling Agencies❑ E-chx will pay dues• Sponsorship and Support of Agent Friendly LegislationACTION FUND DONATION SECTION Check or CC EFT amountPAYMENT SECTION$____________ or $____________/mo.❑ CHECK - Annual payment only.Please make payable to NAPAA and mail to the address at the bottom of this application.❑ CREDIT CARD – Annual payment only. I authorize this amount to be charged to my credit card.(Please complete the information below)Card type: ❑ VISA ❑ MasterCard ❑ Discover ❑ American ExpressName on account ______________________________________ Amount to be Charged: $__________ (Annual only)Account Number ________________________________________ Expiration date __________ Security code________Address on Card _____________________________________________________Zip on Card_____________________Signature of Cardholder _________________________________________________ Date ____________(3/09 EF)❑ EFT - Monthly (attach or fax voided check)I understand that the amount stated above will be deducted from my checking account every month until instructed otherwise.I have enclosed a voided check and understand that the withdrawals will occur on or about the 20 th of every month.Authorization Signature: _____________________________________________________________Date ____________❑ E-chx will pay my dues – I am an E-chx client processing payroll at least twice per month.NATIONAL ASSOCIATION OF PROFESSIONAL ALLSTATE AGENTS, INC.Please fax application Toll Free to: 866.627.2232Mail application to: P. O. Box 7666, Gulfport, MS 39506Call Toll Free: 877.627.2248 • E-Mail: HQ@napaausa.orgNote: You do not have to be a member to donate to the NAPAA Action Fund