Mail: info@fwcebc.org

Membership Form

If you have any questions regarding membership, please contact Peter Cardillo (813) 875-4003 or pcardillo@spspension.com.

* Required fields
Membership Status(*)
This field is required.

Full Name(*)
Invalid Input

Title
Invalid Input

Company(*)
Invalid Input

Mailing Address(*)
Invalid Input

Address 2
Invalid Input

City(*)
Invalid Input

State(*)
Invalid Input

ZIP(*)
Invalid Input

Telephone(*)
Invalid Input

Extension
Invalid Input

Email Address(*)
Invalid Input

Area of Specialization
Invalid Input

Professional Designations requiring CE credits
Invalid Input

Preferred Areas of Interest

Invalid Input

Comments or suggestions regarding meeting topics and overall Council activities
Invalid Input

Sponsoring Council Member (if any)
Invalid Input

I do not authorize

Invalid Input

Annual membership dues are $325, additional members from the same company annual membership dues are $250. You may pay with PayPal or mail a check on the next page.
I intend to pay membership dues via(*)
Invalid Input

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)(*)
Invalid Input

Date(*)
Invalid Input

Enter the letters(*)
Enter the letters
RefreshInvalid Input

Please type the letters you see above the text box. If you cannot make them out, please hit the Refresh button next to the text box.