Membership Application

Beneficiary/ Salary Replacement Form

*Social Security:	RequiredInvalid format.
*Email:	Required.Invalid format.
*First name & Middle name:	Required
*Last name:	Required.
*Address:	Required.
*City:	Required.
*State:	Required.
*County:	Required.
*Zip:	Required.Invalid format.
*Home phone:	Required.Invalid format.
Other phone:	Required.Invalid format.
*Work phone:	Required.Invalid format.
PRIMARY BENEFICIARY *Claims are paid to the listed beneficiary regardless if the status of the relationship changes. THIS BENEFIT IS AT NO ADDITIONAL COST TO YOU!
*Social Security:	A value is required.RequiredInvalid format.
*Birth date:	A value is required.Required.Invalid format.
*First name & Middle name:	A value is required.Required
*Last name:	A value is required.Required.
*Address:	A value is required.Required.
*City:	A value is required.Required.
*State:	Please select an item.Required.
*County:	A value is required.Required.
*Zip:	A value is required.Required.Invalid format.
*Home phone:	A value is required.Required.Invalid format.
Other phone:	A value is required.Required.Invalid format.
*Work phone:	A value is required.Required.Invalid format.
SECONDARY BENEFICIARY ** Secondary beneficiary is eligible for benefits if primary beneficiary is unavailable
*Social Security:	A value is required.RequiredInvalid format.
*Birth date:	A value is required.Required.Invalid format.
*First name & Middle name:	A value is required.Required
*Last name:	A value is required.Required.
*Address:	A value is required.Required.
*City:	A value is required.Required.
*State:	Please select an item.Required.
*County:	A value is required.Required.
*Zip:	A value is required.Required.Invalid format.
*Home phone:	A value is required.Required.Invalid format.
Other phone:	A value is required.Required.Invalid format.
*Work phone:	A value is required.Required.Invalid format.
*** If no beneficiary is named or if beneficiary is unavailable, benefits will be paid to the member's estate.
Signature:	Required.
Your signature is required to process this form!!
Please read and fill this form to make sure the fields are correct, print two copies and mail one to: Southern States PBA 2155 Highway 42 S McDonough, GA 30252 DO NOT FORGET TO SIGN THIS APPLICATION!