Please complete the Corporate Membership form below. This is a requirement for FCCMA membership.

Personal Data:

Contact Person:

Title:

Company:

Street Address:

City, State:

County:

Zip Code:

Telephone:

Fax:

After Hours Number:

Email:

Spouse/Partner:

Corporate Data:

Type of Services Company Provides:

Governments in Florida that your Company has worked with:

ICMA Member?:

If yes, ICMA Membership Category:

Year Joined:

How did you hear about FCCMA?

If you have worked with governments in Florida, please indicate below your two references:

Name:

Title:

Contact Number:

Name:

Title:

Contact Number:

We may contact these persons to verify their endorsement of you?

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By my signature below, I certify that the information supplied above is true to the best of my knowledge. I have read and agree to comply with the Code of Ethics of ICMA and FCCMA to the extent that they apply to private companies.