ALABAMA INDEPENDENT INSURANCE AGENTS, INC.
ON-LINE DUES PAYMENT FORM FOR ASSOCIATE MEMBERSHIP

AGENCY NAME .....................
NAME AND CONTACT:................
PERSON ..........................
CORPORATE OFFICER OR PRINCIPAL...
MAILING ADDRESS .................
CITY ........ STATE. ZIP.
PHONE NUMBER. FAX NUMBER.
EMAIL ADDRESS ...................
WEB DOMAIN NAME OR URL ..........
Annual Dues $415.00