IIAM ASSOCIATE MEMBERSHIP APPLICATION
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Company:
Address:
City:State:Zip:
Phone:Fax: E-mail:
Website Address:
Main Contact:
If branch, Headquarters Address:
Line of Business:

Please check the following items that are of interest to you:

Interaction with my local (county) IIAM Chapter        Publications:  providing articles, news releases
IIAM Education Programs                                           Serving on selected IIAM committees
Program/Function Sponsor                                        Being an information source for IIAM
V.I.P Access to association leadership/staff               Other_____________________________

Annual Membership Investment:  $300.00 (NON-REFUNDABLE)

Please make certain that application is faxed or mailed to IIAM even if payment is made by credit card!

Date:______________________________________Signature:__________________________________________
Mail application to:
Independent Insurance Agents of Maryland, Inc.
2408 Peppermill Drive, Suite A
Glen Burnie, MD.  21061