Application for Membership
Long Island Accountants and Financial Planners Network
Name
*
First Name
Last Name
Company
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
*
Format: (000) 000-0000.
Work Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Profession
Public Accountant
In House Accountant
Insurance Agent
Financial Planner
Attorney
Real Estate Broker/Agent
Business Broker
Mortgage Broker
Other
Practice Area - Attorney
*
Practice Area - Insurance Agent
*
Life
Health
P&C
Other
Attach Business Card
*
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Please Provide the Name, Address and Phone Number for Two (2) Business References
Reference 1
*
First Name
Last Name
Reference 1 Phone Number
*
Format: (000) 000-0000.
Reference 1 Email
*
example@example.com
Reference 2
*
First Name
Last Name
Reference 2 Phone Number
*
Format: (000) 000-0000.
Reference 2 Email
*
example@example.com
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Membership Fee Secure Payment
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Membership Fee
$350.00
$
350.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
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