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NAIS MEMBERSHIP APPLICATION
Customer E-Mail
Important: Enter a valid e-mail address. Receipts will be sent to this address.
*E-Mail:
Billing Information
*First Name:Same name as on your card
Middle Initial:
*Last Name:
*Address Line 1:Where your statement is mailed
Address Line 2:Apt. or Suite No.
*City:
*State
*Country:
*Zip Code:
*Phone:
Company Name:
State License # (If Required)
Areas of Specialization
Web Site Address:
Credit/Debit Card Information
*Card Number:No dashes or spaces please
*Expiration Month:From your card
*Expiration Year:From your card
*Card Brand:
*CVV2: Card Security Code
 

Enter the security code shown above
in UPPER CASE.
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