Membership Application

APPENDIX 1
APPLICATION FOR MEMBERSHIP OF THE
Private Health Insurance Intermediaries Association Inc.

I,……………………………………………… of ……………………………………….. (name and occupation) (address)
desire to become a member of the Association

In the event of my admission as a member, I agree to be bound by the rules of the Association for the time being in force.
Signature of Applicant…………………………………….                  Date        /       /
________________________________________________________________________
I,…………………………………………………., a member of the Association,
nominate the applicant, who is personally known to me, for membership of the Association.
Signature of Proposer:…………………………………….                 Date        /       /
________________________________________________________________________
I,……………………………………………………, a member of the Association, second the nomination of the applicant, who is personally know to me, for membership of the Association.
Signature of Seconder……………………………………..                 Date        /       /