Name
Home Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Information:
Employer
Department
Title
County
Work Phone
Home Phone
FAX
E-mail
URL
Professional Information:
Degree(s)
License(s)
Nat. Credential
And/or Certificate(s)
Legislative Information*:
(Residence only)
State Senator
or District
State Rep. or District
*Not sure? Check with your local
Elections Office or look on your voter card.
Anual Membership Fees:
NEW! Apply online using PayPal
Full time SSW = $50.00
Associate/Retired = $25.00
Full time Student = $20.00
Joining or renewing
membership in SSWAA = $40.00
Make separate check payable to SSWAA
and we will forward it for you.
NOTE: SSWAA membership when
NOT renewing with FASSW is $75.00.
**Mail form and check to:
Vicki Barreneche
8716 Cobbler Place
Tampa, FL 33615