Florida Health and Human Services Board, Inc.
Membership Application        

Please provide the following  information: 

Name

Title

Organization

Work Phone

FAX

E-mail

URL

 

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

    Membership Dues

Individual

$100

Organization

$200

                                                                                                                                                                                  

We are not set up to process this form electronically. You must print this application on your own printer  and mail it in. Membership dues are tax deductible as are any additional contributions. We have received a favorable determination from IRS recognizing our tax exempt status. 

Make check payable to:
FHHSB
17920 Burnside Drive
Lutz, Florida 33548
(813) 949-4673
(813) 949-4673 (fax)