Florida Emergency Preparedness Association

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					                                     FLORIDA EMERGENCY PREPAREDNESS ASSOCIATION
                                                      400 Capital Circle SE, ST 18-263
                                                               Tallahassee, FL 32301
                                                                         850-274-1835
                                                                          www.fepa.org

        FLORIDA EMERGENCY PREPAREDNESS ASSOCIATION
              2012 MEMBERSHIP APPLICATION FORM
Dear Member:

Thank you for your interest in joining FEPA. Please complete this application form for
your 2012 FEPA membership dues. Annual Membership dues for the 2012 calendar year
are $75.00 per person. Student membership dues are $25.00 per person.

MEMBERSHIP APPLICATION FORM:

Please provide us with your membership information:

  Name:
  Title:
  Company:
  Address:
  City:                     State:             Zip Code:
  Work Phone:                                  Work FAX------
  Email Address:
  FEPA Area:

To pay using Mastercard/Visa/American Express write the account information and
expiration date below then email to erainey@fepa.org or mail to the address above.

Card # ________________________________          Expiration date ___/____
Security Code: ________ Name as Appears on Card: ___________________
Billing Address of Card: __________________________________________
City: ____________________ State: ______________ Zip: _____________
Pay online at http://www.fepa.org/

  Make check payable to:

  Florida Emergency Preparedness Association, Inc.
  Federal ID # 59-2389989
  400 Capital Circle, SE ST-18-263
  Tallahassee, Florida 32301

                      THANK YOU FOR YOUR SUPPORT!

				
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