Membership Form
New Member Renewal
(First Name*) (MI*) (Last Name*)
Contact Information: (Where you whish to receive the FAS Newsletters and special FAS E-mail's)
(Address*)
(Address2)
(City*) (State*) (ZIP*)
(Phone)
(E-mail Address)
Work Information:
(Company Name)
(Address)
(Address2)
(City) (State) (ZIP)
(Phone)
(Work E-mail Address)
Questionnaire:
      How did you hear of the Florida Adlerian Society?
 
 
What are your expectations of the Florida Adlerian Society?
 
 
How many conferences do you plan on attending in one year?
0 - 1 2 - 3 4 - 5 6 or more
Explain how you can benefit from the Florida Adlerian Society and how it can benefit from you.
 
 
What committees interest you the most?  (Please check any of the following that interest you.)
Bookstore Membership Newsletter Social
Education/Programs Public Relations Parent Study/Family Education
Would you like to receive the FAS Newsletter?  (Please check/circle one of the following choices.)

No

Yes, by E-mail

Yes, by USPS

Please mail the completed form and your $20 check (made payable to F.A.S.) to:
Florida Adlerian Society,2111 W. Swann Avenue, Suite #104
Tampa, FL 33606
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