MEMBERSHIP APPLICATION/CONFERENC

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MEMBERSHIP APPLICATION/CONFERENCE REGISTRATION FORM

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Please note that in order for you to be a member with the organization you MUST be a, Law Enforcement Officer, Corrections Officer, Prosecuting Attorney, Sexual Assault Nurse, or a profession that specializes in the care and assistance with victims of sexual related crimes.

Take a moment and fill in the form below. Once this form is completed press the “Submit” button. You will be taken to a page where you can select and pay for membership or conference registration.

Please indicate New Member or Renewal * New MemberMember Renewal

Please indicate which form you are submitting. *

Personal Information

Title: *

(i.e. Detective, Attorney, Nurse......etc)

Full Name: *

(first, middle, last name)

Home Address

Street Address

Address continued

City

Zip

State

Home #: *

( )

Office #: *

( )

Cell #: *

( )

SS#: *

Email: *

Birthday: *

Nursing Certification

Florida License #:

If you hold a certification not listed, please indicate here:

Sexual Assault Training - Adult and Adolescent

Name of Program:

Location:

Dates Attended:

Hours of Training:

Approximate:

Exams Performed:

Depositions:

Court Testimony:

Preceptorship completed: * YesNo

Work associated with degree:

Sexual Assault Training - Pediatric

Name of Program:

Location:

Dates Attended:

Hours of Training:

Approximate:

Exams Performed:

Depositions:

Court Testimony:

Preceptorship completed: * YesNo

Work associated with degree:

Employer Information

Employer Name *

Street Address

City

Zip

State

Hire Date:

Job Description:

Please send your CV to:

Suzy Williams

FSCIA-SANE Coordinator

26 Big Buck Trail

Ormond Beach FL 32174

Comments

If paying by check, follow these instructions. Otherwise press "Submit" to be taken to Online Payment

Make checks payable to: Florida Sex Crimes Investigators’ Association,Inc.

P.O. Box 122138, Ft. Lauderdale, Florida 33312

If you are sending payment for the membership or conference via snail mail, please fill out this form then print prior to submitting. Enclose the printed copy with your check.

Please Enter Check or PO Number for Tracking.

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