VB ASSOCIATION MEMBERSHIP APPLICATION FORM 2010-2011

Voluntary Benefits Association (VBA)
Please complete this form for submission to VB Association
Mail: 1128 Royal Palm Beach Blvd Suite #
138 Royal Palm Beach, FL 33412
Fax to: 866.547.1639
Phone : 561.792.4418
E-Mail : info@VoluntaryBenefitsMagazine.com

Company / Member's Information

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Company : *

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Contact Person's Information

Please enter the main point of reference/contact person that the VBA should communicate with regarding membership.

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Select Membership Level

	Corporate Premier	$5,000
	Corporate	$2,000
	Insurance Company	$2,000
	Employer Membership	$2,000
	Enrollment Firm	$1,000
	Technology Provider	$1,000
	Health Insurance Agent	$500

Terms & Conditions

By Clicking here I Agree to the Terms & Conditions applied for the Membership of the Voluntary Benefits Association (VBA).

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