YES,
I'm self-employed and I want the NASE working for me!

Please complete the following information:
This for is ONLY for residents of South Dakota, New Jersey and New York.

I am:
submitting a membership application.
requesting more association information.

Name:
Home address:
City:
State:
ZIP:
Day phone:
Evening phone:
E-mail address:
Business name:
Business street address:
City:
State:
ZIP:
# of employees:
Business phone:
Fax #:

To help us stay in touch with our members,
please take a minute to answer the following questions:

Type of business:
Other, please specify:
Date of birth:
Gender:male female
Marital status:married single divorced widowed
Level of education:

Are you interested in receiving information about the NASE's endorsed insurance plans? Yes No


FOR APPLICATIONS:

Type of Membership
One year preferred - $360

I understand my annual dues of $360 will be apportioned between the NASE and its wholly owned Member Services subsidiary. I also understand benefits are offered at the sole discretion of the NASE and may vary by availability, vendor or state of residence of the Member. I understand $7 of my dues are not tax deductible as a business expense as these monies are allocated for legislative advocacy, and that $2 of my dues are for a one-year subscription to Self-Employed America.

Credit card: VISA MasterCard

Card number:
Card expiration date:
Name on card (exactly as it appears):

By submitting this payment information, you give permission for the processing of your membership in the National Association for the Self-Employed, Inc. as well as permission to charge the credit card you have provided. You also agree to hold the NASE, and its agents, harmless from any damages occurred with processing this information.

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