Name:__________________________________

Title:___________________________________

Organization:____________________________

_______________________________________

Address:________________________________

City:___________________________________

State:________________ Zip:______________

Telephone;______________________________

Facsimile:_______________________________

E-Mail:_________________________________

[Please make checks payable to FLATOA, Inc.]

Individual - $50.00
Agency - $100.00

(Please reproduce application for each agency member and identify the one voting member for
your agency.)

Student – No Dues
Name of School: _______________________

Please forward to:
FLATOA, Inc.
Garth T. Ashpaugh, CPA
1003 Kewannee Trail
Maitland, FL 32751
407.645.2020 fax 407.645.4070