Membership Application

Personal Data
Name*
First Last
Title
Organization
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Alternate Email
Work Phone*
Work Fax
Cell Phone
County*
*Annual Base Salary (Required for Full Members)
Partner
ICMA Recognized Government
- YES
ICMA Member
- YES
ICMA Membership Category
Previous FCCMA Member
- Yes
Have you ever been convicted of a felony or misdemeanor?*
- YES
- NO
If yes, please describe.
Have you ever been denied membership or had your membership revoked in ICMA or any other state association?*
- YES
- NO
Education
Education (Undergraduate and Graduate)
Please state degree earned, institution, state and year earned.
Work Experience
Work Experience
Please begin with your most recent position. Please state years served, position title, employer and state.
Membership Categories (See Website for Category Descriptions)*
- Full (Annual dues are $3 for each $1,000 base salary)
- Affiliate (Annual dues are $150)
- Life (Annual dues are $25)
- Subscriber (Annual dues are $25)
Endorsement
The FCCMA membership policy requires that each applicant receive one endorsement from an affiliate, full or life FCCMA member or no endorsement if the applicant is an ICMA member. Please indicate your reference by stating name, title and organization. We may contact this person to verify his/her endorsement of you.
Employer's Signature (Only if not the CAO and Applying for Full Membership)
- YES
- NO
As chief administrative officer for the applicant's city/county, I hereby certify that the above-named individual is qualified for full membership status as outlined in the FCCMA Bylaws which states: A person who serves in a full-time position appointed by the administrative head of a local government within the boundaries of Florida and who has received an endorsement from that administrative head as having significant general administrative responsibilities. We may contact this person.
Applicant's Signature*
- YES
- NO
By my affirmation, I certify that the information supplied above is true to the best of my knowledge. I have read and agree to comply with the ICMA Code of Ethics and understand that completion of the online ethics review is required. Additionally I understand that four hours of ethics training is required to maintain membership.
Where did you hear about FCCMA?
What are you looking for in the Association?

Membership Application

Florida City and County Management Association Membership Application

Personal Data

Education

Work Experience

Florida City and County Management Association
Membership Application