Pay by Credit Card or Pay by eCheck eCheck Payment Type of Membership* Agency Company Associate Retired OrganizationOrganization for which this payment is being made. Does not apply to Retired. Contact Name*Name of person processing payment. Contact Email*Email of person processing payment. Total Dues Amount Being Paid*Refer to Dues Structure. Agency Only - Total # of Full-time P&C AgentsPlease send full list of member names and email address to carol@piavadc.com.Email*Email address the receipt should be sent to. eCheck Bank Information Name on Account Bank Name Routing Number Account Number CheckingSavingsAccount Type
