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Membership Application Reference Form

TO BE COMPLETED BY FIRM'S EXECUTIVE OFFICER OR PRINCIPAL

TWO REFERENCES REQUIRED - THIS FORM MAY BE PHOTOCOPIED

*Denotes mandatory. If not applicable, type N/A.

Applicant Firm Name *

Applicant Firm Contact *

Address Line 1 *

Address Line 2

City *

State/Province/Region

Zip/Postal Code *

Country *

WSIA member references must be completed by a WSIA voting member. A WSIA voting members is a Wholesale Member, Insurance Market Member or Associate Member. WSIA Service Members may not be used as references.

Reference Name *

Title *

Member Firm Name *

WSIA Membership No.

Address *

City *

State

Zip/Postal Code *

Phone *

Email Address *

1. How long have you known the Applicant Firm? *

2. What is relationship to the Applicant Firm? *

3. To the best of your knowledge is the Applicant Firm properly authorized/licensed to transact business? *

Yes

No

4. Do you feel this the Applicant Firm would be an asset as a member of WSIA? *

Yes

No

5. Do you know of any specific issues that would preclude the Applicant Firm from membership in WSIA? *

Yes

No

Please explain. *

6. Do you have any additional comments to support the Applicant Firm’s membership in WSIA?

7. Do you recommend the Applicant Firm for membership in WSIA? *

Yes

No

Signed *

clear

Date * +