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Wed Dec 12, 2018
Revision Date:

2018-2019

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

:

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

If you wish to pay by credit card, please notify Mrs. Maura Angle.  You will be emailed an invoice from which you can pay your membership dues.


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