FBLA Pennsylvania - Membership Application Virtual Chapter

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:
Bruce E. Boncal
PA FBLA Executive Director
PO Box 5085
Jersey Shore, PA 17740

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.