Application for The Medicare Supplement
Accredited Advisor Designation

 (For mail-in application with payment by check or money order go to Mail-In Application.
Use this form to submit the on-line electronic application below,
...then... Step 2.  Pay by credit card using SECURE On-Line Payment)
      

NAME
  
AGENCY/COMPANY NAME
  
DAY PHONE NUMBER
  
FAX NUMBER
  
E-MAIL ADDRESS (IF APPLICABLE—PRINT CAREFULLY)
  
MAILING ADDRESS
  
SHIPPING (STREET NEEDED)
  
CITY, STATE, ZIP
  

Resident Insurance Producer’s License No.:
  

State (Not needed if an Insurance Company
Employee):
  

SSN (For State CE Credit):
  
  

I herewith submit a $200.00 payment to: MSAA Designation for the MSAA Designation Package.  I understand that if I earn, and am awarded this designation, the designation does not allow me to associate myself in any way with Medicare, or any other government entity, nor am I allowed to hold myself out as a representative of such.  I understand that, should I not satisfactorily complete both examinations within three months of the date of receipt of course materials, I will be allowed an additional thirty days in which to satisfactorily complete both examinations.
If I do not satisfactorily complete both examinations there will be a $25.00 refund.

I agree      Date   

To complete this on-line process:
   Step 1. Press the “Submit Application” button above and
   Step 2. make payment by credit card using PayPal, go to Secure Payment.
                                       or
For mail-in application and to pay by check or money order, go to Mail-In Application.