Registration Form

NSSTA Women's Caucus

Membership Registration
Choose Membership Type Desired*

NSSTA Women's CaucusFriends of NSSTA Women's Caucus (for Gentlemen NSSTA Supporters)
Name*

First NameLast Name
Company*
Gender*

MaleFemale
Birthday
Month and Day
Contact Information
Business Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Mailing Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
Business E-mail*
Personal Email
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Office Phone*

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Practice Information
Primary Specialty*
(Plaintiff/Defense, Liability, Work Comp, MSP Compliance, Trusts, etc.)
No. of Years in Structured Settlements Industry*
Professional and/or Education Designations
Mentorship (Program in Development)

I'm interested in being a Mentor.I'm interested in working with a Mentor.
Sponsorship

I'm interested in sponsoring an event.I'm interested in organizing sponsorship for an event.
I am interested in helping with:

ProgrammingPlanning In-Person MeetingsBook ClubNewsletter ContributorBlog ContributorWebsite MaintenanceOther
I am interested in hearing more from the NSSTA Women's Caucus about the following:
Please share your thoughts.
I agree to conduct myself in accordance with the NSSTA Statement of Ethics and Professional Responsibility.
E-Signature Name*
Date*

MonthDayYear
Date
After submitting your registration, the NSSTA Women's Caucus will review your application and contact you with any additional questions. Thank you for your interest in the NSSTA Women's Caucus!
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NSSTA Women's Caucus

Contact Information

Practice Information