Philadelphia Loss Conference Membership Application

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New Membership _____     Renewal Membership _____

Last Name ____________________ First _________________  Middle ____

Residence Address ______________________________________________

City __________________________ State _____  Zip Code _____________

Home # (   ) ___________________  Work # (   ) ____________________

Employer _______________________________________________________ 

Position _________________________________ Years Employed _______

Business Address _______________________________________________

City ___________________________  State _____  Zip Code ___________

E-Mail Address __________________________________________________

I hereby submit this application for membership along with my check for $25.00 made payable to THE PHILADELPHIA LOSS CONFERENCE. If my application is approved and a membership is granted, I agree to abide by the Constitution and By-Laws as approved and amended by the vote of the majority of the membership.

Signature ___________________________________ Date ______________

Members Signature ______________________________________________ 

Print Member Name ______________________________________________

Send Application & fees to:
Kreigstein, Kim & Wright, P.C.
Attn: Dan Wright
111 South Independence East
Philadelphia, PA 19106