I hereby request enrollment as a member of Peoples Benefit Alliance and understand that the dues for standard membership are $9.00 annually. I also understand that my membership dues are non-refundable, and my failure to remit membership dues will result in loss of eligibility to participate in any of the Association sponsored programs or discounts.

First Name:	Last Name:
Street Address:	City:
State:	Zipcode:
Email:	Phone Number:

Upon payment you will receive a membership kit or access to the membership portion of the website. If you have further questions please call us at 800.992.8044.

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