AMERICAN POLICYHOLDER ASSOCIATION MEMBERSHIP APPLICATION

APA Company Membership

All information submitted is confidential and will not be shared with the public.

Contact Person / Applicant Information
Company Contact First Name*
Company Contact Last Name*
Email*
Cell*
Secretary / Assistant - Phone or Email
Polo Shirt Size*
Secondary Representative Information
Secondary Company Contact First Name*
Secondary Company Contact Last Name*
Email*
Cell*
Polo Shirt Size*
Business Information
Business Name*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How did you hear about the APA?*
Check all that apply and please list the source
- Referred by Friend/Associate
- Saw APA Presentation/Display
- Social Media
- News Media
- Association Journal
- Other
Please list source
Please specify source
Payment Information
Company Membership (Annual)
Price: $2,500.00
Auto billed annually.
Total
$0.00
Credit Card*
Payments are processed securely by Stripe.

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Fiduciary & Ethics Pledge
Your membership to The American Policyholder Association is contingent upon you agreeing to the Fiduciary & Ethics Pledge. You must read this document carefully before submitting your application. Checking below certifies that you are legally authorized to act on behalf of your company/organization in agreeing to this pledge, and have read and agree to it. Further, you will communicate these responsibilities to all members of your company or organization and will monitor their behavior to assure compliance. Lastly, you understand that the APA reserves the right to revoke your membership if you violate the pledge.

VIEW THE PLEDGE
Fiduciary & Ethics Pledge Agreement*
- I have read and agree to the Fiduciary & Ethics Pledge Agreement
Submit Application
Terms of Use Agreement*
- By submitting this form I accept the APA Terms of Use (including billing agreement) and I certify that the information contained herein is accurate and truthful.

AMERICAN POLICYHOLDER ASSOCIATION MEMBERSHIP APPLICATION

APA Company Membership

Contact Person / Applicant Information

Secondary Representative Information

Business Information

Payment Information

Fiduciary & Ethics Pledge

Submit Application

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