Join K-Klub


	Join the K-Klub

First Name:
Last Name:
Company Name
Company Mailing Address:
City:
State:
Zip:
Company Physical Address:
City:
State:
Zip:
Phone:
FAX:
Email Address:

	Oregon/Idaho Affiliate Chapter Membership**	$1500.00
	Washington/Alaska Affiliate Chapter Membership**	$1200.00
	Discounted Membership for both Affiliate Chapters**	$2400.00

Associated PIA Western Alliance Membership $377 Value**

FREE


	Payment Options:

Please charge me the full amount.

Please bill me.


	Please Complete the following survey to help us serve you better and give you the type of exposure most suitable for your needs.


	Provide a contact name and number for agency members who would like to do business with you:

First Name:		Last Name:		Phone:
First Name:		Last Name:		Phone:

Yes	No	Are you currently appointing new agents?
Yes	No	Are you interested in providing an educational class or workshop sponsored by PIA?
Yes	No	Can you provide meeting space for PIA meetings or classes?


	Which states are you currently active in?

Alaska	Idaho	Nevada
Arizona	Montana	Oregon
California	New Mexico	Washington

Please tell us more about yourself. If possible email a detailed description of your business, products, and services. This information is for a catalog we send to PIA Western Alliance members twice a year describing associate members benefits to our members. Some of this information will also be used in our newsletters. A brochure, flyer, or written information will suffice.

If you would rather print and mail this form, please send to:

Attn:Gary Wolcott
PIA Western Alliance
3205 NE 78th St., Suite 104
Vancouver, WA 98665


	Comments:

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Please Note: Membership is for one year beginning and ending in the month that we receive your first payment

** Membership dues include the PIA Western Alliance Main Street Journal subscription price of $12.00