Associate Membership Application Associate Membership Application Company/Firm Name:*Contact First Name:*Contact Last Name:*Professional Designations:Contact Title:*Address* Principal Address: Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone:*Toll Free:Fax:Email:* Taxpayer ID #:Website Address: FEIN #:BACKGROUNDYear Business was Established:Please provide a brief description of the nature of your operations below:Is the company engaged in, owned by, associated or affiliated with or controlled by any other business interest?YesNoIf yes, please give a brief explanation below:Professional Associations to which you belong: Select All WSIA FAIA PIA Other If Other, please list below.Please list 3 Surplus Lines Agencies representing you in Florida: Surplus Lines Agency Actions Edit Delete There are no Agencies. Add Agency Maximum number of agencies reached. How did you hear about us?Why are you interested in joining?How do you rate your experience with the surplus lines industry?PositiveNegativeIndifferentCommentsFSLA ANNUAL MEMBERSHIPAssociate Membership ($1,250)Associate Membership ($1,250)SurPac Suggested ContributionYes, I would like to contribute $1,000 to the SurPac!No, thank you.Yes, I would like to contribute a unique amount to the SurPac! Payment InformationBilling Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Total $0.00 Notice: Florida Surplus Lines Association dues are not deductible as a charitable contribution for federal tax purposes, but may be deductible as a business expense. The current tax code eliminates the portion of your dues attributable to lobbying expenses. It has been determined that 34% of your dues are used for these purposes, therefore only 66% of your dues are deductible as a business expense.BY SUBMITTING THIS FORM, I HEREBY DECLARE THAT THE ANSWERS GIVEN WITH RESPECT TO THE FOREGOING QUESTIONS ARE TRUE, COMPLETE, AND ACCURATE WITH NO MISREPRESENTATION, OMISSIONS, OR ANY OTHER CONCEALMENT OF FACT.Name of Applicant:Title of Applicant:Date of Application: Date Format: MM slash DD slash YYYY CAPTCHA SURPAC CONTRIBUTION LEGISLATIVE UPDATES MEMBERS ONLY WEBINARS