Online Membership Form

Florida
American Sign Language


	FASLTA MEMBERSHIP FORM Annual membership dues per school year is due by August 15th of each new school year. We have two (2) categories of membership: Voting members: $25.00 OR Supporting members: $20.00 (non-voting) Please fill in the form below, and you can pay online by credit card, using PayPal. It's secure, does not give US your credit card info, and you do not need to have a PayPal account in order to use this feature. First Name:* Last Name:* Street:* City:* State:* Zip code:* Florida County: E-mail:* Home Phone:* Home Phone is:* Voice TTY Both VideoPhone School Name: School City: Work Phone: Work Phone is: Voice TTY Both VideoPhone DEMOGRAPHICS Please check one: Deaf Hard of Hearing Hearing MEMBERSHIP INFORMATION ASLTA Certification level:* Provisional Qualified Professional no certification level Florida DOE Endorsement?* YES NO I am a (check one):* NEW member Renewing member Please note that once you click the SUBMIT button, you will be taken automatically to the PayPal site, where you can make your payment. Follow the payment instructions on the PayPal site. Your membership IS NOT COMPLETE until payment is made. Please SAVE your payment verification email as proof of payment. Please Choose:* FASLTA 1-year Regular (voting) membership $25.00 USD FASLTA 1-year Supporting membership $20.00 USD Total: $0.00 USD Should be Empty: