FASSW Membership Application

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	Florida Association of School Social Workers Membership Application Form Print out and mail to address below
	PLEASE TYPE OR PRINT Name __________________________________________________________________ Home address ___________________________________________________________ _______________________________________________________________________ County of Residence ______________________________________________________ Home Phone ________________________ Fax_________________________________ Email __________________________________________________________________ Work Information Employer _______________________________________________________________ Department _____________________________________________________________ Work title ______________________________________________________________ Professional Information Degree(s) ______________________________________________________________ License(s) ______________________________________________________________ National Credential(s) _____________________________________________________ And/or Certificate(s) ______________________________________________________ *Legislative Information (Residence only) Degree(s) ______________________________________________________________ License(s) ______________________________________________________________ National Credential(s) ____________________________________________________ &/or Certificate(s) _______________________________________________________** * Not sure? Check with your local Elections Office or look on your voter card.
	Annual Membership Fees: (Expires one year from Application) If you are a new member, or are renewing membership but have a change in your basic personal data shown on the form, remember to fill out an application and forward it to the FASSW at the address below. ____ Full time SSW = $50/$90/$120 (1/2/3yrs) ____ Associate = $25/$45/$65 (1/2/3yrs) ____ Student = $25.00 ____ Check if you are renewing your FASSW membership Remember to make check payable to: FASSW Please forward all Membership inquiries to: membershipfassw@fassw.org Alternative Payment: Print form and mail with check to:* FASSW Treasurer P.O. Box 195656 Winter Springs, FL 32719-5656 For more FASSW information visit our Web Site: http://www.fassw.org

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