PO Box 1446     Ft. Myers, FL 33902

 MEMBERSHIP APPLICATION

 CHAPTER 7

Annual Dues:  $195.00 

 £ Contractor Member      £ Associate Member

Sponsor:  _______________________________________ FRSA Member     £ Yes       £ No

Company Name:______________________________________________________________

Contact Person:    ________________________________ Title:  _______________________

License Number: (if applicable) __________________________   Year Issued: ____________

Mailing Address:  _____________________________________________________________________________

City, State, Zip _____________________________________________________________________________

Physical Address:  _____________________________________________________________________________

Work Phone:  (_______) ___________________   Fax:  (________) ______________________

Cell:  (________) _______________ Email Address:  _________________________________

I affirm representation of the above named company and agree to abide by the standards of the SWFRCA by-laws and ethical code.  (Please review By-Laws & Code of Ethics on www.swfrca.com)

Signature:  _________________________________________ Date:  ____________________

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To pay by credit card, please fill out below:

SWFRCA accepts Visa, MasterCard and American Express.

Credit Card # ___________________________________ Expiration Date:  ________

Name on Card:  ______________________________ Amount:  _________________

Authorized Signature:  __________________________________________________

 If paying by check, please mail completed application and payment to:

 SWFRCA, P.O. Box 1446, Ft. Myers, FL.  33902 or email This e-mail address is being protected from spambots. You need JavaScript enabled to view it