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
*
Work Phone Number
*
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
*
Reference 1 Email
*
example@example.com
Reference 2
*
First Name
Last Name
Reference 2 Phone Number
*
Reference 2 Email
*
example@example.com
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Membership Fee
$
350.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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