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

Personal Data:

Name:

Title:

Government Affiliation:

Street Address:

City, State:

County:

Zip Code:

Telephone:

Fax:

After Hours:

Email:

Salary (Required for dues calculation):

Spouse/Partner:

ICMA Recognized Government?:
YesNo

Do you have a college degree?
YesNo

If yes, what degree?

College Attended:

Date of Graduation:

Other Education:

ICMA Member?
YesNo

If yes, ICMA Membership Category:

Year Joined:

Have you ever been convicted of a felony or misdemeanor?
YesNo

If yes, please explain:

Have you ever been denied membership or had your membership revoked in ICMA or any other state association?
YesNo

Where did you hear about FCCMA?

What are you looking for in the Association?

Experience in Government:

1. Name of Government:

Position:

Years Served (Dates):

2. Name of Government:

Position:

Years Served (Dates):

3. Name of Government:

Position:

Years Served (Dates):

4. Name of Government:

Position:

Years Served (Dates):


I, , chief administrative officer for the municipality or county of , hereby certify that the above-named individual is qualified for full membership status as outlined in the FCCMA Strategic Plan and Membership Directory.



Signature, Chief Administrative Officer




Our membership policy requires that each applicant receive 2 (two) endorsements from full FCCMA members. Please indicate below your two references:

1. Name:

Title:

Contact Number:

2. Name:

Title:

Contact Number:

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

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.