Membership Application - National Society of Insurance Premium Auditors

Individual Membership Application

NSIPA 2020-2021 Membership Application
July 1, 2020 - June 30, 2021

Membership Dues

Membership Type *

Contact Information Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Middle

Last Name *

Suffix

Title

Informal Name

Company

Address 1 *

Address 2

Address 3

City *

State

Zip Code *

Country

Website

Personal LinkedIn URL

Personal Twitter URL

Personal Facebook URL

Professional Photo/Headshot

Phone Number *

Fax Number

CCMail

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
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 Payment Details

Amount to Charge :

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.

Bank Name:
Bank Account Holder Name:
Routing Number:
Account Number:
Account Type:

Name on Card:

Card #:

Expires:

CSC (What's this?):

Save payment method for future purchases

Enable Automatic Renewals?

Select "Yes" in order to be enrolled in automatic membership renewal. The above payment method will become your saved payment method, overwriting anything that may have been previously saved and will be used for future renewals. You can change the automatic renewal setting or saved payment method at any time in either the "Payment Method" or "Membership Auto-Renewal" tabs where you edit your profile.

No Yes