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Type of Membership
New Voting Member Resident
Renew Voting Member Non-resident
Agency/Company Name
Address
City State Zip
Phone Fax
Customer ID # Web Address
PA Agency SL License
Is your Agency a MGA Wholesaler Retailer Other
Is your Agency a member of IIABA PIA CIAB NAPSLO AAMGA
Please list the name(s) of the persons who should received PSLA Member Services communications.
Use a separate form for additional names if needed.
Name Email
Would you like your contact information to be published on our website? Yes No
Would you like to serve on a Committee? Yes No
Would you be interested in serving on the Board when a vacancy occurs? Yes No
Please check if you wish to be removed from the membership rolls of PSLA
Please call Debbie Smailer at 610-594-1340, ext. 103 or email memberservices@pasla.org if you have any questions.
Form Completed by: