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Password Confirm Password E-mail Address Confirm E-mail Address Full Name LEAVE THIS BLANK Primary Membership Information Primary Contact Name of Law Office, Agency, or Business Primary Email Type SelectProfessionalAttorneyAgencyCaseworkerAdoption Services ProviderOther Please Specify Other Street Address Street Address Street Address Line 2 City State Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Mailing Address Is your street address and mailing address the same? Yes No Street Address Street Address Line 2 City State Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Misc_section Office Phone Fax Number Florida Bar # Florida License # State(s) Where LicensedFL Services Provided Adoption MediationAdult AdoptionsAgency and Attorney On-line marketingBirth Parent CounselingBirth Parent InterviewsCase Management SoftwareContested AdoptionsDependency InterventionsDomestic Adoptions Intercountry AdoptionsDomestic Home StudiesHome Studies And Post PlacementIdentified Adoption ProgramIntercountry Home StudiesInterstate (ICPC)AdoptionsLegal AssistancePost Adoption Picture and Letter SoftwarePost Placement SupportPrinting servicesRelative AdoptionsStepparent AdoptionsSurrogacyTraditional And Extra Care Adoption ProgramVideo CreationWaiting family profile creationWebsite DevelopmentOther Florida Regions All of FloridaCentralEast CoastNorthSouthWest Coast Specify other services Have you ever been convicted of a crime, or do you now have any criminal charges pending against you other than minor traffic violations? Yes No If YES to the above question then please explain below Have you ever been professionally disciplined, or do you now have pending any matter regarding renewal, revocation, or suspension of your license? Yes No If YES to the above question then please explain below Have you ever been sued by a client, or do you now have pending against you any claims by a client? Yes No If YES to the above question then please explain below Total Years As Licensed Attorney or Other Adoption Professional Colleges/Universities Attended, Dates, and Degree(s) Obtained Publications Professional/Civic Organizations (Include Offices Held) I Agree to the Terms and Conditions Last update: Feb 5, 2020I have read and agree to the FAC list serv policies. The Listserv policies can be viewed by clicking here.I acknowledge that I have read, received, and retained a copy of the policies for participation in the Florida adoption council's list serv (revised March 2019). I have also reviewed the said policies with each member of my office staff. I will maintain a copy of said policies at all times and personally insure that any postings to the list serv by me, or by any member of my office, comply with said policies. Regarding participation in, and use of information shared on the list serv, I understand that use of the list serv is a privilege, and that any failure by me, or by any member of my staff, to comply with said policies will constitute grounds for immediate suspension or permanent revocation of my access to the list serv. I further understand that it may also be grounds for immediate suspension or revocation of my Florida adoption council membership. I agree to indemnify and hold harmless the Florida adoption council, including its directors, from any liability resulting from any list serv postings, or comments, made by me or by any member of my office staff.I hereby swear, affirm, and certify that the statements in this initial membership application are true and correct. I understand and agree that submitting this application for membership does not necessarily mean that the board of directors will approve my application and grant membership. I further understand and agree that my being granted membership in, and being permitted to remain a member of, the Florida adoption council is within the sole absolute discretion of the organization's board of directors, and that its decision is final. 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