Membership Application

Membership Application/Renewal Form

Complete the membership application form below to join or renew your FCIE membership.

"*" indicates required fields

Organization Name

Is this a new membership or a renewal?*

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Membership Type

Membership Type*

Institutional - $375 per year

Affiliate - $225 per year

Individual - $50 per year

Organization Address*

Street Address Address Line 2 City State ZIP Code

Name - Organization Representative*

Organization Representative

First Last

Organization Representative - Title*

Organization Representative - Department

Organization Representative - Phone*

Organization Representative - Email*

Study Abroad - Name

First Last

Study Abroad - Phone

Study Abroad - Email

Billing Contact - Name*

First Last

Billing Contact - Email*

Enter Email Confirm Email

Billing Contact - Phone*

Billing Contact

Payment Method*

Credit Card

Check

Total Amount Due (Check)

Mail check to:

Please mail your check made payable to FCIE to the address below:

Carolyn Haines
Treasurer
Florida Consortium for International Education
2821 Hampton Place Court
Plant City, FL 33566

Total Amount Due (Credit Card)

Payment Method*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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Name

This field is for validation purposes and should be left unchanged.