Mail: info@fwcebc.org

Membership Form

If you have any questions regarding membership, please contact David Montgomery at (813) 868-1930 or firstvp@fwcebc.org.

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Membership Status(*)
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Full Name(*)
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Title
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Company(*)
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Mailing Address(*)
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Address 2
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City(*)
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State(*)
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ZIP(*)
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Telephone(*)
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Extension
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Email Address(*)
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Area of Specialization
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Professional Designations requiring CE credits
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Preferred Areas of Interest

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Comments or suggestions regarding meeting topics and overall Council activities
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Sponsoring Council Member (if any)
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I do not authorize

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Annual membership dues are $225, additional members from the same company annual membership dues are $150. You may pay with PayPal or mail a check on the next page.
I intend to pay membership dues via(*)
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By signing this form, I affirm that the information submitted within is true and accurate. I understand that my membership application will be submitted to the Board of Directors for approval (affirmative vote of a majority of the Board of Directors). I also understand that the Council is a tax exempt entity organized under Section 501(c)(3) of the Internal Revenue Code for educational purposes and, in that regard, the use of the Council membership roster or members' list in any form for advertising to members or solicitation of business is strictly prohibited. I further understand that such conduct may result in suspension or revocation of my membership.
Signature (type your full name)(*)
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Date(*)
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Enter the letters(*)
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