MISSISSIPPI BAIL AGENTS ASSOCIATION
805 South Wheatly, Suite 150
Ridgeland, MS 39157

Office: 601-899-8599  Fax: 601-899-85987

MEMBERSHIP APPLICATION
2008-2009

(PLEASE TYPE OR PRINT - APPLICATION MUST BE FILLED OUT COMPLETELY)

NAME: ____________________________________________________________________________________________________________

ADDRESS: _________________________________________________________________________________________________________

CITY: ______________________________________________ STATE: ________________________________ ZIP: ___________________

MISSISSIPPI DEPARTMENT OF INSURANCE LICENSE #: ________________________________________________________________

COMPANY NAME: _________________________________________________________________________________________________

COMPANY ADDRESS: _______________________________________________________________________________________________

CITY: ______________________________________________STATE: ________________________________ ZIP: ____________________
PHONE NUMBERS: Office: ___________________________________________________

Home: ___________________________________________________

Fax: _____________________________________________________

Email: ___________________________________________________
 
TYPE MEMBERSHIP APPLIED FOR:
 
 
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INDIVIDUAL MEMBERSHIP - Fee $100.00 entitles member to one vote and full membership privileges.
 
 
GENERAL AGENCY MEMBERSHIP - Fee $500.00 entitles company to name one voting members and to name four associate members. Each associate member may upgrade to voting status by paying an additional $100.00 during fiscal year.
 
 
INSURANCE COMPANY MEMBERSHIP - Fee $1,000.00 entitles company to name one voting members and to name six associate members. Each associate member may upgrade to voting status by paying an additional $100.00 during fiscal year.

 

**ATTENTION COMPANY AND AGENCY MEMBERS**
A COMPLETE APPLICATION IS NEEDED FOR EACH MEMBER.
 
I agree to abide by the By-Laws and Code of Ethics of the association.
 
 
________________________________________________________
Printed Name
 
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Signature
Notice: All application must be approved by a majority vote of the Board of Directors