National Flood Insurance Program Agent and Lender Registration Form
Name ______________________________________________________ Company/Organization ______________________________________ Street ____________________________________________________ City ____________________ State _____ Zip Code ____________ Phone _______________________ Fax _________________________ Email _____________________________________________________
Workshop Information:
(check one) ___ Agent ___ Lender
Workshop Location (City, State) ___________________________
Workshop Date _____________________________________________
Workshop Fee Schedule:
Flood Alert Agent Training Workshop (half day). . . $30 Flood Alert Agent Training Workshop (full day). . . $45 Lender Workshop . . . . . . . . . . . . . . . . . . $25
Registration Information:
Please fill out and print this .pdf form and mail it along with the
appropriate fee to:
NFIP Bureau & Statistical Agent
Room N111
7700 Hubble Drive
Lanham, MD 20706
Make checks payable to the NFIP.