Contact Information Agreement: I understand that the NSSTA CSSC/MSSC Committee must favorably consider this application prior to acceptance. By submitting this form, 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. Full Name Company Email Address Street Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Telephone Number Structured Settlement Industry Experience Do you currently hold a CSSC Certificate? Yes No If yes, in what year did you receive your CSSC Certificate? Please describe your involvement in NSSTA during your career: Please include memberships or Co-Chairs of Committees, Board Memberships, etc Please describe your role (ie: broker, admin, life company, etc) in the structured settlment industry: Number of Years in the Structured Settlement Industry: