Personal Information

Last Name:	First Name:	Middle Name:
Suffix:	Preferred Name:	Gender:
		F M
Home Address:	Home P.O. Box:	City:
Home Street Zip Code:	Home Mail Zip Code:	County of Residence:	State:
		Please SelectAlachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Miami-Dade Desoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Monroe Marion Martin Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington	Please SelectMilitary Address Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington DC Delaware Exempt Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Foreign Address
Home Phone:	Email Address:	Certified in Florida?:
Certificate Num.:	Certificate Date:	Out of State Certificate Num.:
Out of State Certificate Date:	State	AICPA Member:	AICPA Member Num.:

Method of Payment

Cardholder Name: Card Number: (Please include dashes) Expiration Date: Card: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2003 2004 2005 2006 2007 2008 VISA MASTERCARD

Preferences

Preferred Chapter:	Send General Mailings To:	Send CPE Mailings To:
Atlantic Brevard County Broward County Central Florida Dade County East Coast Emerald Coast Florida Keys Gold Coast Gulf Coast Jacksonville Miami-Downtown Mid-Florida Miracle Strip North Central Florida North Suncoast Polk County Ridge Area Sailfish Sandspur South Dade Southwest Florida St Johns River Suncoast Tallahassee Treasure Coast Volusia County West Coast West Florida Out of State Out of Country	Home Office	Home Office
Exclude Me From CPE Promotions?:	Exclude Me From Third Party Mailings?:
Yes No	Yes No
May We Contact You Via Fax?:	May We Contact You Via E-Mail?:
Yes No	Yes No

     

Firm Information

Firm Name: [Part 1]	Firm Name: [Part 2]	Are You a Partner / Owner ?:
		Yes No
Firm Address:	Firm P.O. Box:	Mail Stop:
Firm City:	Firm State:	Firm Street Zip Code:
	Please SelectMilitary Address Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington DC Delaware Exempt Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Foreign Address
Firm Mail Zip Code:	County of Firm:	Firm Foreign Country:
	Please SelectAlachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Miami-Dade Desoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Monroe Marion Martin Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington
Firm Phone:	Firm Phone Extension:	Direct Phone:
Firm Fax:	Direct Fax:	General Business Code:
		Please Select Agribusiness Automobile Dealership Banks/ Credit Unions Colleges and Universities Construction Contractors Distribution Entertainment Food Franchising Government (Federal/ Government (Local) Health Care Hospitality/Tourism Insurance Manufacturing Media Military Not for Profit Oil and Gas Professionals Real Estate Retail Transportation
Specific Business Code:	Firm Web Address:
Please Select Local Firm - One Owner Local Firm - Multiple Owners Regional Firm National / International Firm National / International Firm - Big Six Agribusiness Business Services Chamber of Commerce Communications Construction Complimentary Firm Consulting Educational Institution Extractive Facility Finance / Investments Government - Federal Government - Local Government - Miscellaneous Government - State Health Care Insurance Information Systems Legal Leisure Time Media Manufacturing Non-Profit Non-Member Firm - Peer Review Public Utilities Real Estate Retail Sales / Service Transportation Vendor Wholesale Miscellaneous Other

     

Interests

An area of interest is an area with which you have knowledge or a practice area you would like to continue to develop professionally. The FICPA will be using this information to better serve you in the future. (Please select up to 15 interest codes.)
	Accounting and Auditing		Agribusiness
	Assurance Services		Bankruptcy
	Business Valuation		CIRA
	Communications/Media		Construction
	Controllership		Divorce
	E-Commerce		Education
	Elder Care		Ethics
	Financial Institutions		Financial Services/Investments
	Fraud		Government
	Health Care		Hospitality/Leisure Time
	HUD		Human Resources
	Industry		Insurance
	Internal Audit		Inventory
	Litigation Services		Manufacturing
	MAP		Not-for-Profit
	Peer Review		Professional Services
	Public Utilities		Real Estate
	Retail Sales/Services		Retirement Planning
	Taxation-C Corp,S Corp, LLC, LLP etc		Taxation-Estate, Gift and Trust
	Taxation-Federal		Taxation-Individual Income
	Taxation-International		Taxation-Payroll
	Taxation-State		Technology
	Transportation		Wholesale