Monthly Membership / Join In

Now you can pay your dues monthly from your credit card.

VASOUTHWESTERN VIRGINIA (ROANOKE)

VASOUTHWEST dues: $80.00 / 12 = $6.67
VASW dues: $64.00 / 12 = $5.33
NABIP dues: $386.00 / 12 = $32.17
Total dues: $44.17 per month

Personal Information
Prefix  
First Name  
Middle Name  
Last Name  
Suffix  
Designation(s)
(separated by commas)		  
Informal Name  
Gender  
Birth Date   m/d/yyyy
Website  
Company  
Cell Phone  
Practice Areas   Long Term Care
Individual Plans
TPA
Disability
Large Group
Self Insured
Managed Care
Small Group
Medicare
Retirement
RX-PBM
Dental
Worksite Mktg
Name of Local NABIP Chapter  
Referred by (If applicable)  
Work Information
Address 1  
Address 2  
City  
State/Province  
Zip/Postal Code  
Phone  
Fax  
E-mail  
Please note: your membership confirmation will be sent to this address.
This email will serve as your login to your Member Portal - access to NABIP's online membership information.
Home Information
Address 1  
Address 2  
City  
State/Province  
Zip/Postal Code  
Phone  
Fax  
E-mail  
Please note: This information will be used to determine your voting district for state and federal advocacy efforts.
Contribute to NABIPPAC Candidate Fund (Optional) - NABIPPAC Information
These guidelines for contributions are merely suggestions. You may contribute more or less than the guidelines suggest, and the NABIP will not favor nor disadvantage you by reason of the amount of your contribution or your decision not to contribute. A contribution to a Political Action Committee is not tax deductible. Federal law prohibits corporate or business donations to a federal PAC. Please make certain that your check or credit card is your personal account.

If you are making a NABIPPAC donation, please make sure to fill out your Company, Work Address & Occupation information on the form.
Occupation   (required)
 
Suggested Levels
One Time Monthly Draft
Member $150 $12
Bronze $365 $30
Silver $500 $42
Gold $750 $63
Capitol Club Levels
Platinum $1,000 $85
Diamond $2,000 $170
Double Diamond $3,000 $250
Triple Diamond $5,000 $415
Other $ $
Membership Dues
Dues Amount   $44.17
Payment Information
Monthly Payment by   Visa   MasterCard   AmEx/Optima   Discover
Card Number  
Exp. Date  
OR
Monthly Payment by   Bank Draft
Routing Number  
Account Number