EmailMe Form - ASPPA Credentialed Membership

Name *

Prefix First MI Last

Company: *

(provide company name, even if home address is noted below)

Company Owner’s Name(s)

Title *

I am the owner

Home Address

Business Address

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Work Phone *

### - ### - ####

Home Phone

### - ### - ####

Home ZIP Code (for government affairs purposes):

Work Email Address: *

Personal Email Address

Application for: *

CBS™ (Cash Balance Specialist)

CPC™ (Certified Pension Consultant)

QKA® (Qualified 401(k) Administrator)

QKC® (Qualified 401(k) Consultant)

QKS (Qualified 401(k) Specialist)

QPA™ (Qualified Pension Administrator

APM (Associated Professional Member)

I am an APA (Accredited Pension Administrator)

I am an ERPA

(IRS ERPA Enrollment No.)

Which position best describes your job function? *

Which business most closely describes your place of employment? *

Please indicate the SEC or state insurance license you currently hold:

Series 6

Series 7

Series 65

State life or annuity insurance license:

State

License number

Experience Requirements:

QKA, QKS, QKC, CBS, QPA, CPC: *

I have completed Retirement Plan Fundamentals (RPF) and earned my certificate; Or

My manager attests that I have at least three years of experience in retirement plan-related matters. Your manager will receive an email to verify your experience requirements.

Manager's Name:

First Last

Manager's Title:

Manager's Company:

Manager's Email:

Is your Manager an ASPPA credentialed member?

Yes

No

Code of Conduct:

Have you been found guilty of a felony, violation of insurance or securities regulations or any violation of the code of ethics of any professional or business
organization? *

Yes

No

If yes, please explain.

*

I have read the ASPPA Code of Professional Conduct and if my application is accepted I agree to abide thereby. I certify that the information provided in this application is true and correct to the best of my knowledge. The ASPPA Code of Conduct can be found online: https://www.asppa-net.org/footer/code-of-conduct/

Signature *

Clear

Date: *

MM / DD / YYYY

Payment Information

Dues are paid on a calendar year cycle. New membership dues are prorated based on join date.

Dues Payment: *

Jan 1 - June 30: $750 (dues through 12/31)

Jul 1 - Oct 31: $375 (dues through 12/31)

Nov 1 - Dec 31: $750 (includes next year’s dues)

Retired or Government Employee: $100 (dues through 12/31)

Add NAPA Membership ($100 — Dues through 12/31)

Add NTSA Membership ($100 — Dues through 12/31)

I am paying by: *

Check

Credit Card

Type of Credit Card Payment *

Mastercard

Visa

Amex

Discover

Name as it appears on card *

First Last

Credit Card Payment *

Signature *

Clear

Check Payments:
Paying by check? Please print a copy of your completed application and send with check payment to: ASPPA, P.O. Box 34725, Alexandria, VA, 22334-0725.

Questions? Please call us at 703-516-9300.

Tax Deductions:
Dues, contributions or gifts to ASPPA are not deductible as charitable contributions; they may be deductible, however, as ordinary and necessary business expenses. Federal law prohibits a tax deduction for the portion of membership dues attributable to lobbying expenses incurred by the organization. Consequently, for 2025, 18% of your dues are non-deductible in accordance with this provision.