February 2015 large text - page 24

2555 Porter Lake Drive, Suite 106 • Sarasota, FL 34240 • Ph: (941) 952-9293 • Toll-free: (866) 930-FSPA(3772)
Fax: (941) 366-7433 • E-mail: Membership@FloridaPoolPro.com • www.FloridaPoolPro.com
Company Name:
Contact Name:
Mailing Address:
City: State: Zip Code: Primary county of work:
Web site: E-Mail:
Telephone: Cell: Fax:
List any FSPA references / who recruited you (Company + Contact):
FSPA Office Use: Date Rec’d: _________ ID: __ __ __ __ __ PW: __ __ __ __ __ __ JD: __ __ __ __ __ __
Cat: _______ MYr: _______  FPP ____ / ____ Chapter: _______ To Chapter: ____ /____ /____ MP ___ CP ___ Web ___
Chapter Use: Bd App’d: ____ / ____ / ____ Approved by Chapter (Authorized Signature):
Florida Swimming Pool Association
(Please print clearly)
Membership Category: Dues/Fees Amount: $ /yr. /qtr. /mo.  MSDS: FREE! Check #
Credit Card # CVV _____ Exp. Date (month / year): ____ / ____
Card Signature: ______________________________________ Date: _____ / _____ / _____ ZIP code: ______________
 I do NOT wish to receive faxes or e-mails regarding FSPA activities, events or member benefit programs. (Benefit program information may come from an affiliated third party.)
Membership Categories, Dues & Membership Fees Schedule, Membership Criteria and Code of Ethics on reverse side.
Company membership includes all company employees. Some member programs, such as free CE, Design Awards and
the scholarship program, require dues and fees to be paid in full before entry (no payment plans).
Business Tax #: _______________________  Attached Copy of Certificate of Insurance / Workers’ Comp Exemption
Please indicate all types of work done by your company (check all that apply):  Pool / Spa Service (Pool Cleaning / Water Treatment)
 Pool / Spa Builder / Installer  Pool / Spa Service (Full Service Including Repair / Refinishing / Equipment Servicing)
 Building / Health / Licensing Official  Landscape Architect  Sub Contractor - type of work: __________________
 Consultant - type: ____________________  Retail Store  Other: _____________________________________
I authorize the FSPA to charge my credit card as indicated on this form.
Important Notice: Dues payments to the Florida Swimming
Pool Association are not tax deductible as charitable
contributions for federal income tax purposes. However,
dues payments may be deductible as an ordinary and
necessary business expense, subject to any exclusion
for lobbying activity. The current percentage used for
lobbying that is not deductible for income tax is 12%.
(see list on reverse)
Has company applying been in business at least 1 year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “no”, please contact the FSPA office for a provisional membership application.
Does company have any unresolved consumer complaints? (If “yes”, describe each and attach to this form) . . . . . . . . . . . . . . .
Has company or any of its principals been found guilty of any criminal offense within the last three years (excluding traffic offenses)?
If “yes”, provide date and nature of conviction __________________________________________________
Has company or its principals ever used the FSPA logo in violation of FSPA bylaws? . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .
Has company previously been a member of the Florida Swimming Pool Association? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
If Company engages in any work requiring State Contractor Certification or State Registration, provide the name and licensee number.
Qualifier Name: _______________________________________________ 
State Certified / Registered Contractor’s License Number:
(Occupational License)
Rev. 1/15
Annual Membership Application
DOB
By submitting payment (in full or on a payment plan), the company below agrees to membership in FSPA in the appropriate
Chapter, agrees to abide by the code of ethics, criteria for membership (printed on the reverse side) and the bylaws, and
acknowledges that the logo and name may be used only by members after approval of membership.
 I do NOT wish to receive text messages from FSPA.