Renew Your Membership : Members : Arkansas Self Insurers Association (ASIA)

Membership Dues are $350.00. Hit the Submit Button at the bottom of this form will complete your payment. You will receive a confirmation email.

Note: If you require using US mail for payment, please remit to the following address after submitting the form below.
Arkansas Self-Insures Association
P.O. Box 11926
Fort Smith, AR 72917

If you have any questions you may contact: Melinda Cox, 479-264-8236.

9zj5r60e0nve

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Phone

Company Name

Do you have any contact changes to make on your membership?

Please list any changes with your organization for membership. (Example: Contact Email, Addresses, Phone numbers)

Fee

Membership Fee - $350

Credit Card Information

Cardholder Name

Credit Card #

Visa MasterCard American Express Discover

Expiration Date

Security Code

Cover the fee associated with this online transaction?

Yes, I will pay an additional {transaction_fee} to cover the cost of this transaction.

Cover the fee associated with this online transaction?

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Renew Your Membership

Credit Card Information

Join Us!