Membership Request Fax Form
Fax Form to 866-353-8732
Please Print All Information
Office Name:___________________________
Your Name:__________________________________________ (First, Last)
Main Office Address:_________________________________________
Office City:________________________ Office State: _______ Number of Locations__________
Years in Business_____ Email Address_____________________@___________________. com
Contact Phone Number: ( )_________ ©\ _________
Cell Phone: ( ) __________©\______________ (only for important emergency contacts or text messages where time sensitive request are needed for the industry)
Signature:_______________________________ Date_________________
Signature authorizes NITPA to charge your card for the yearly membership as listed below.
Membership Yearly: $250.00 Initial Office Location
Additional Office Locations $75.00 each
Membership: Includes a "Market Share data report" for one initial office. Additional office market share reports are $50 per request and may require an additional 7 days for extraction.
Payment Method: Circle one ¨C American Express, Visa, Master Card, Discover or check
Credit Card Number____________________________________ Expiration Date___________
Security Code__________________ (3 on back except American Express 4 on front)
Name as it appears on card:_______________________________________ Billing Address on Card:______________________________________city_______________State____ Zip______
Names and Numbers of those you¡¯d like to refer to join NITPA
Name_______________________________ Number___________________
Name_______________________________ Number___________________
Return via Fax to 866-353-8732 No Cover Page is needed . NITPA is a non-profit group founded in Montgomery Alabama and nationally recognized as the only independent lobbying voice for Tax Preparers in the U.S. by Business Week Magazine. All information is kept confidential. ____ Yes____N0 ( I would like to make an additional contribution to the Political Action Committee headed by NITPA to help increase the lobbyin efforts that will defend my industry and individual business rights in the amount of $___________. This will be listed as a separate onetime charge on your account. If Mailed: NITPA P.O. Box 5022 Montgomery, Al. 36103 Attn: Treasurer Ginger Strickland, CPA
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