2019
Membership Payment Form - Part I
Please check all that apply:
Corporate Membership -$5,000
MGA/Wholesaler Membership -$2,500
Retail Agency Membership -$500
Individual Membership - $295
Grand Total Due $ _________________________
Please make checks payable to MarketScout.
I hereby agree to apply for the above 2019 CIPC Membership.
Company Name: _______________________________________________________________________
Contact Name: _____________________________Title/Position: ________________________________
Mailing Address: _______________________________________________________________________
City: ____________________________________ State: _____________________ Zip: ______________
Phone: ______________________________________ Fax: ____________________________________
E-mail: _______________________________________ Website URL: ___________________________
(MEMBERSHIP PAYMENT FORM - PART I)
Tel: 972.934.4264
Email: [email protected]
www.privateclientcouncil.com