KEYS COUNCIL FOR MATH AND SCIENCE EDUCATORS
INDIVIDUAL MEMBERSHIP APPLICATION
CONTACT INFORMATION
First Name Last Name Your Subject Interest (Choose all that apply) Mathematics Science
Personal Information
Home Address
Mailing Address
City State Zip Code Home Phone Personal e-mail
Last 4 digits of Social Security Number
Employment Information
School/Business/Institutional Address
Institution Type Choose One Public Non Public Position Choose One Teacher Administrator Other Grade Level (Choose all that apply) PreK K 1 2 3 4 5 6 7 8 9 10 11 12 Higher Education
City State Zip Code County
Phone Fax Number
Work E-mail
I was referred by a KCMSE member
Individual Membership
Keys Council for Math and Science Educators (KCMSE) Regular Membership (one year) $10.00
Florida Council of Teachers of Mathematics (FCTM)
Regular Membership (one year) $25.00
Regular Membership (two years) $50.00
Florida Association of Science Teachers (FAST)
Regular Membership (one year valid through October) $20.00 Choose One New Membership Renewal Membership
TOTAL AMOUNT METHOD OF PAYMENT (Make checks payable to KCMSE)
Check Money Order
(You will be asked to print information once you submit, be sure that your computer is connected to a printer)
SPONSORSHIP APPLICATION
First Name Last Name Organization/Business Name
Sponsorship Donation Levels
Blue Level $50 - $99 Green Level $100 - $199 Gold Level $200 and above Sponsorship Amount
METHOD OF PAYMENT (Make checks payable to KCMSE)
Choose One Check Money Order
Sponsorship Information
Type Choose One Business Individual Other
E-mail (You will be asked to print information once you submit, be sure that your computer is connected to a printer)
