AMERICAN POLICYHOLDER ASSOCIATION JOINT MEMBERSHIP APPLICATION

APA Joint Board Advisor Application

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

Contact Person / Applicant Information
Full Name*
Title/Relationship to Business*
Email*
Cell*
Fax
Facebook
Twitter
LinkedIn
Board Advisor Referrer Information
Please list the name of the APA Board Advisor who referred you to the APA*
Business Contact & Location Information
Business Name (must be the same as the referrer)*
DBA*
Business Email*
Business Phone*
Polo Information
Please select a size:*
Payment Information
How would you like to pay?*
- Annual
- Monthly
Joint Board Advisor (Annual)
(Per Year - Billed Automatically)
Price: $5,000.00
Joint Board Advisor (Monthly)
Price: $420.00
Per Month - Billed Automatically. (12 month minimum term.)
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 JOINT MEMBERSHIP APPLICATION

APA Joint Board Advisor Application

Contact Person / Applicant Information

Board Advisor Referrer Information

Business Contact & Location Information

Polo Information

Payment Information

Fiduciary & Ethics Pledge

Submit Application