Membership Application - The National Structured Settlements Trade Association

Membership Application

(For the PDF version, click here.)

I. Company Information

Please use the space below to provide the requested information about the company applying for membership.

Organization Name: *

Your Name:

Mailing Address: *

City: *

State: *

ZIP: *

Phone: *

FAX:

e-mail: *

II. Membership Category

Please use the space below to select category into which the above company best fits.
Use the attached definitions from the NSSTA Bylaws to guide your selection.

Check All that Apply:

Provider Company

Producer Company

User Company

Associate

Please describe your company's involvement in structured settlements:

*

III. Company Affiliation

Please list the names of any parent company, affiliates, subsidiaries or other company related to
the applicant company that is involved in the structured settlement business and indicate their
involvement in structured settlements.

Corporate Parent:

Structured settlement activity:

Is this company an NSSTA member?

yes
no

Subsidiary:

Structured settlement activity:

Is this company an NSSTA member?

yes
no

Other Affiliate:

Structured settlement activity:

Is this company an NSSTA member?

yes
no

IV. Agreement

I understand that the NSSTA Membership Committee and the NSSTA Membership Board of
Directors must favorably consider this application prior to acceptance. By signature hereto, I
declare that the facts herein are true and complete to the best of my knowledge. I also state that
my organization, voting and professional members are actively involved in, associated with, or
have an interest in the furtherance of periodic payment of compensation on account of personal
physical injuries as set forth in Article II of the NSSTA Bylaws.

Name: *

Title:

By clicking "Submit Form," you agree to the above statement.