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

Personal Data:

Name:

Program:

University Attending:

Degree Attaining:

Number of Hours:

Estimated Graduation Date:

Street Address:

City, State:

County:

Zip Code:

Telephone:

Fax:

Email:

Spouse/Partner:

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?

Work Experience:

If you are only enrolled part-time, are you currently working?
YesNo

If you answered yes, how many hours, your title and name of business or government:

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.