Brevard County Bar Association 2017-2018 Dues Registration / Renewal Statement Membership Fiscal Year: July 1, 2017 through June 30, 2018 Thank you for renewing your BCBA membership! The information you provide on this form will be used to create the Brevard County Bar Association Membership Directory and to maintain accurate membership records. Name* First Last (As you wish to be listed in the Membership Directory)Firm NameLAW FIRM Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CREDIT CARD BILLING ADDRESS (street name, number and zip code must match those on record with your issuing bank.)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code The street name, number and zip code must match those on record with your issuing bank.Telephone*FaxEmail* Website Florida Bar #*Date admitted to Florida BarDo you use courier service?* Yes No Areas of InterestThe 2018 Membership Directory will contain a section listing Brevard County Bar Association members by their areas of interest and board certifications. This section will assist with referral cases. Your first listing is $25.00. Each additional listing is $10.00. Please include this optional fee with your BCBA dues. Number of Areas of Interest*None1 Listing - $25.002 Listings - $35.003 Listings - $45.004 Listings - $55.005 Listings - $65.006 Listings - $75.007 Listings - $85.008 Listings - $95.009 Listings - $105.0010 Listings - $115.00Board CertifiedAdmiralty & Maritime LawAdoption LawAntitrust & Trade Resolution LawAppellate PracticeAviation LawBusiness LitigationCity, County, & Local Government LawCivil TrialCondominium & Planned Development LawConstruction LawCriminal AppellateCriminal TrialEducation LawElder LawHealth LawImmigration & Nationality LawIntellectual Property LawInternational LawJuvenile LawLabor & Employment LawMarital & Family LawReal Estate LawState & Federal Government & Admin PracticeTax LawWills, Trusts & EstatesWorkers' CompensationNot Board CertifiedAdministrative LawAdoption LawAppellate PracticeAviationBankruptcyCivil RightsCollectionsCorporation & Business LawConstruction LawCriminal LawCustoms LawEminent DomainEmployee Benefits, ERISAEntertainment LawEnvironmental & Land Use LawEstate Planning & ProbateFranchise LawGeneral PracticeGuardianshipImmigration & NaturalizationJuvenile LawLabor LawLocal Government LawMarital & Family LawMaritimeMediationMedical Malpractice, PlaintiffPatent LawReal PropertySocial SecurityTrademark & CopyrightTrial Practice - CommercialTrial Practice - Personal InjuryWills, Trusts & EstatesOtherAnnual BCBA Membership Dues/FeesCheck All that ApplyRegular Dues ($100)Attorneys admitted to practice law for five (5) years or less ($75)Public service and/or governmental attorneys licensed to practice law for less than (10) years. Includes: Assistant State Attorneys and Assistant Public Defenders of the 18th Judicial Circuit; Assistant Regional Counsel of the 5th District; active duty attorneys with any of the seven federal uniformed services residing or practicing law in Brevard County; full-time staff attorneys with Brevard County Legal Aid Inc.; full-time attorneys with Central Florida Legal Services Inc.; and full-time staff attorneys employed by any state agency or department of Brevard County. ($50)Join the Young Lawyer's DivisionOptionYoung Lawyers Division - Active Members Age 35 or younger and/or practicing less than five (5) years. ($20)Young Lawyers Division - Associate Membership All others ($25)I do not wish to join. ($0)Would you like your firm Website linked to the Brevard County Bar Association website? (One fee per firm)*NoYesCriminal - $25.00Civil - $25.00Both - $50.00Firm Website AddressCOURTHOUSE ACCESS CARDSNoYes - $50.00Your current courthouse access card becomes inactive on 8/31/2017. For security reasons, you will NOT be allowed to bypass security with an expired BCBA card. Don't get stuck waiting in line at the courthouse. Keep your courthouse access card active! Payment Options I Accept the following Courthouse Access Card Information If you have a courthouse access card that allows you into the courthouse through the card reader, the courthouse access fee will assure that your card remains active. If you have an old BCBA courthouse access card or this is your first courthouse access card, you will need to request to see Deputy Hargraves at the Viera courthouse to have your photo taken and your new courthouse card printed. I certify that I am currently a member in good standing of the Florida Bar and the Brevard County Bar Association (BCBA). I further certify that, as a condition of issuance of a courthouse access card: I will not allow anyone else to utilize my courthouse access card to gain access to any Brevard County courthouse or for any other purpose; I will not bring articles prohibited by any statute, ordinance, administrative regulation or policy of the State of Florida or Brevard County, its officers, employees or agents, into any Brevard County courthouse or cause anyone else to do so; and I will not bring a weapon or firearm into any Brevard County courthouse or cause anyone else to do so, and I consent to a weapons search of my person or possessions by security or court personnel as requested. I agree to indemnify and hold harmless the BCBA, its officers, directors, employees and agents, from and against any and all liability, claims, actions, causes of action and attorney's fees and costs through appeal arising out of (or in connection with) the issuance, use, misuse or loss of my BCBA courthouse access card. I further agree that, in the event any claim or action is brought against the BCBA, its officers, directors, employees or agents (individually or collectively), as a result of my violation of the terms and conditions of this application, I will accept the tender of the defense of this claim or action or be responsible for the defense of such claim or action until its final conclusion, including an appeal. I understand and agree that any violation of the foregoing conditions will result in the automatic loss of all courthouse card access privileges, and I will immediately surrender my courthouse access card to the BCBA and may not reapply for another courthouse access card for one (1) year from the date of surrender. I understand that courthouse access cards are issued under the authority and control of the Board of County Commissioners of Brevard County, Florida, and (unless revoked) are valid for one (1) year expiring on August 31st annually.Payment Options*Pay NowCredit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name I authorize the Brevard County Bar Association to process this charge on the credit card above. (You will receive a detailed email/receipt when you click 'Submit').SignatureTotal $0.00 Please click the "submit" button only once and wait for a confirmation to be displayed. This will ensure that you are charged only once. If, after clicking the "submit" button, you do not receive an e-mail confirmation of this transaction, please contact Terrie at 321.254.8801 or via email at email@example.com to ensure that this transaction was processed successfully.Confirmation* I have read and understand the text above. CommentsThis field is for validation purposes and should be left unchanged.