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Membership Form
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Membership Form
TNSIA Membership
2019 Membership Fees: Self-Insured Employers $500 | High Deductible Employers $500 | Government Entities (Municipalities) $500............................................. 2019 Associate Membership Fees: Attorneys $750 | Other $750
Company Name
*
Company Address
*
Company Address 2
Company Address - City
*
Company Address - State
*
Company Address - Zip
*
Company Address - Country
*
Primary Contact (First Name)
*
Primary Contact (Last Name)
*
Primary Contact Email Address
*
Primary Contact Phone
*
Additional Company Representatives
Please list: First & Last Name, Email, Phone
Membership Level
*
Self-Insured Employers
High Deductible Employers
Government Entities (Municipalities)
Attorneys
Other
Please Select One of the Following
Membership Fees
*
Price:
$500.00
Quantity:
Membership Fees Self-Insured Employers $500 | High Deductible Employers $500 | Government Entities (Municipalities) $500
Associate Member Fees
*
Price:
$750.00
Quantity:
Associate Membership Fees: Attorneys $750 | Other $750
Payment Type
*
Online (PayPal)
Offline (Check via Mail)
To pay by credit card, select Online/Paypal as your option. Please note, cancellation refunds will exclude PayPal Fees. To pay by check select Offline, and mail check to PO Box 158341 Nashville, TN 37215.
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