Name                                                     Nickname                                                         

Firm                                                                                                                                  

Address                                                                                                                            

City/State/Zip                                                                                                                   

Phone #                                                         Fax #                                                         

State Bar Membership #                                                                                                

Return with membership fee of $150 to:

Georgia Bankers Association
50 Hurt Plaza, Suite 1050
Atlanta, GA 30303