Membership Checkout Membership Level change You have selected the Premium Membership membership level. The price for membership is $575.00 now. Membership expires after 1 Year. Account Information Already have an account? Log in here Are you a current FAC Member * Select No Yes I don't know Username 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 ( used for List Server) * Type Select Professional Attorney Agency Caseworker Adoption Services Provider Other * Please Specify Other Street Address Street Address * Street Address Line 2 City * State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming * Zip * Mail Address Is your street address and mailing address the same? Yes No * Street Address Street Address Line 2 City State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Misc_section Office Phone * Fax Number Your Website Florida Bar # Florida License # State(s) Where Licensed FL Services Provided Adoption Mediation Adult Adoptions Agency and Attorney On-line marketing Birth Parent Counseling Birth Parent Interviews Case Management Software Contested Adoptions Dependency Interventions Domestic Adoptions Intercountry Adoptions Domestic Home Studies Home Studies And Post Placement Identified Adoption Program Intercountry Home Studies Interstate (ICPC)Adoptions Legal Assistance Post Adoption Picture and Letter Software Post Placement Support Printing services Relative Adoptions Stepparent Adoptions Surrogacy Traditional And Extra Care Adoption Program Video Creation Waiting family profile creation Website Development Other * Florida Regions North Central South * 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 Honors and Awards Professional/Civic Organizations (Include Offices Held) Acknowledgment & Payment Section I have read and agree to the FAC Listserv policies. * Acknowledgment By checking this box, I also 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. * Certification By checking this box, 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. * Signature Clear * Title * Billing Address First Name Last Name Address 1 Address 2 City State Postal Code Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands US Armed Forces Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Phone Payment Information We Accept Visa and Mastercard Card Number Expiration Date 01 02 03 04 05 06 07 08 09 10 11 12 / 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Security Code (CVC) (what's this?) 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