Membership Application

*Name	(Name for Member Certificate)
Title
Professional Designations	LTCP CLTC CSA CLU ChFC LTCGS Other
Company/Agency Name
*Mailing Address
*City
*State
*Zip Code
*Telephone
Fax
How did you hear about AALTCI?
*E-Mail	(Used to provide member benefits and access to Members Only page)

Privacy Notice: AALTCI does not share any member personal information with any other company or entity. E-mails are provided solely for communication with members.

AALTCI'S FIND AN AGENT WEBSITE LISTING
Available only to licensed agents and brokers

By providing the information below, I give permission for the American Association for Long-Term Care Insurance to include my name, address and phone number on the AALTCI Find An Agent Directory. If provided below, we will list your E-mail address and Website. Further, I agree to uphold AALTCI's code of ethical standards. Note: The initial Website listing is free with individual paid membership. Subsequent changes requested cost $10.

E-Mail Address to list
Website Address to list

PAYMENT

I wish to join / renew for ( Check ONE ):
1 year ( $49-)
2 years ( $79-)
3 years ( $99-)

Pay By Credit Card (MC. Visa, Amex) I authorize AALTCI to charge the membership fee to my credit card.

*Card Number
*Exp Date
*3 or 4 Dig. Code
*Name on Card
*Credit Card Billing Address