CPAFMA Membership Form

Firm:
Address:
City:    State:    Zip:
Telephone:
Fax:
Website:

Primary Contact (individual responsible for management/administration) * Required
Full Name:   Nickname:   Designations:
Email:   Direct Dial Number:      

Secondary Contact
(designated partner or shareholder) * Required and included in membership fee
Full Name:   Nickname:   Designations:
Email:   Direct Dial Number:      

Please check this box if you are a sole proprietor, solo practitioner or your firm chooses to not include a secondary contact.
Note this secondary contact is included with the membership fee and carries no additional fee.
 
Connections (additional individuals from the firm) * Additional membership fee required
First Connection
Full Name:   Nickname:   Designations:
Email:   Direct Dial Number:      
Second Connection
Full Name:   Nickname:   Designations:
Email:   Direct Dial Number:      
Third Connection
Full Name:   Nickname:   Designations:
Email:   Direct Dial Number:      

Firm size (number of personnel):    Number of Offices: 

Local Chapter Affiliation:   

What is your firm's primary reason(s) for joining?

Networking Survey Results
Publications Conferences

Where did you hear about us?


Is your firm a member of a CPA Firm Association?  Yes     No
If so, which one? 
Other:

Promotional Code:


Membership Categories and Dues (Check all that apply)
Initiation Fee (for all first time members) $25
Firm Member (includes individual responsible for the management of the firm and a designated partner/shareholder) $395/year
First Connection (Additional individual from the member firm - please enter their information above) $25/year
Second Connection (Additional individual from the member firm - please enter their information above) $25/year
Third Connection (Additional individual from the member firm - please enter their information above) $25/year
Consultant Special Interest Group (Consultant SIG)
       (applicant serves as a consultant to the accounting profession) $395/year
Vendor Special Interest Group (Vendor SIG)
       (applicant provides products and/or services to CPAFMA members and firms) $395/year

Total to Charge: $

Payment Method: Invoice Firm or Charge My Visa Master Card American Express
Credit Card Number:  
Card Expiration Date: (mm/yyyy)  
Name on Card: