AMERICAN POLICYHOLDER ASSOCIATION MEMBERSHIP APPLICATION

APA Company Membership

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

"*" indicates required fields

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:

Auto billed annually.

Total

Credit Card

Payments securely processed by Stripe

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.