FCLCA Member Registration Form
Please complete the form below to register for annual membership in the Florida College Learning Center Association (FCLCA).

You do *not* need to complete this form if you are registering for the annual conference as it includes a gift of membership from April 1st - March 30th the year of the conference.

Once you complete and submit the form, you will need to go to PayPal to pay the $25 membership fee to complete the registration process.

FCLCA, a 501(c)(3) nonprofit organization is a state affiliate of NCLCA.
Federal Tax ID # 46-3340084.
Are you a current NCLCA member? *
(NCLCA membership is encouraged but not required. Visit www.nclca.org for more information)
Have you previously been a member of FCLCA? *
(All FCLCA conference attendees will be gifted one-year FCLCA membership. Do NOT complete this form if you are intending to register for the annual conference - unless you want to become a member for the months/year leading up to the conference)
Have you ever attended an FCLCA conference? *
Last Name: *
Your answer
First Name: *
Your answer
Institution Name: *
Your answer
Institution Size *
Institution Type *
Address *
Your answer
Address Line 2
(if needed)
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Additional Address Information if needed
Your answer
Work Phone Number *
Your answer
Secondary Phone number
Your answer
E-Mail Address *
Your answer
COMMENTS
(please include any specific involvement you are interested in - including leadership roles in FCLCA or participation on committees)
Your answer
FCLCA Membership is from April 1 - March 31 each year. Please indicate the specific year you are registering for as a member *
(example 2017-18 would be April 1 2017 - March 31, 2018). Remember, if you attend the annual FCLCA conference, you are gifted one year of membership for the term of that conference.
Your answer
PLEASE NOTE: your membership application is not complete until you submit this form and go to Pay Pal to pay the $25 membership fee
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy