ASSOCIATION OF FOREIGN LANGUAGE

TEACHERS OF DADE COUNTY (FLTDC)

MEMBERSHIP FORM

NAME: _______________________________________________________________

(FIRST) (MIDDLE) (LAST)

HOME/MAILING ADDRESS: ____________________________________________

CITY: ___________________STATE: _______________ ZIP CODE: ___________

HOME PHONE #: ____________________ EMAIL: ________________________

NAME OF SCHOOL: ____________________________ SCHOOL CODE #: ______

ADDRESS: ____________________________________________________

CITY: _______________ STATE: ______ ZIP CODE: _______ FAX : ___________

LANGUAGE (CIRCLE ALL THAT APPLY):

FRE GER ITA RUSS SPA JPN ESOL LAT HEB CHI ARA SUPERVISOR

OTHER: ___________________

ANNUAL MEMBERSHIP (from October 31 to November 1) $25.00

MAKE YOUR CHECK PAYABLE TO: FLTDC

Mail to:

María Sierra

Executive Director

5035 S.W. 140 Ct.

Miami, FL. 33175

SCHOOL CODE: 7271

________________________________________________________________________

MEMBERSHIP PAYMENT: $25.00

CHECK # _______ CASH: _____ DATE: ____________ DEPOSIT # ______