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Tue Jul 25, 2017
Revision Date:

2016-2017

PA VIRTUAL FBLA MEMBERSHIP APPLICATION FORM

To become a member, please fill out the form below.

Title:
First Name: Last Name:
Address:
City: State: ZIP:
High School You Are Currently Attending:
School District in Which Your Home is Located:
Home Phone: Cell Phone:
Email:
Birthday: Grade Level:
Parent Full Name (First/Last):
OPTIONAL INFORMATION FOR DEMOGRAPHIC PURPOSES ONLY:
Race: Gender:

MEMBERSHIP VERIFICATION:

Please read the statement below and verify by typing your names on the appropriate lines.

I verify/give consent for the above named-student to be a member of the PA Virtual FBLA Chapter by typing your name on the lines below:




Member Name

Membership Dues: Total $12 per person
$6 state dues | $6 national dues

 


Parent Name

:

Please enter the characters in the image below:


Payment Options:
Print the membership application and submit a $12 check to:
Mrs. Maura Angle
Virtual Chapter Coordinator/Adviser
Pennsylvania FBLA
33 West Union Street
Nanticoke, PA 18634
 

Pay by credit card by clicking on the following link:
http://www.pafbla.org/creditcards.php

A 3% convenience fee will be added to your total for using a credit card.




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