FMA Membership Order Form
Please submit the following information to order FMA Membership information. Your application will be processed within 10 business days. Omission of information may result in delays. Orders will NOT be processed without payment. Please note: A copy of ALL material(s) to be mailed must be either faxed to 850.222.8030 or emailed to Angela Foster at afoster@medone.org immediately upon submittal of this form. Upon receipt and processing of your application, an invoice will be sent to you.


LICENSE AGREEMENT
This Agreement, made today, is by and between the Florida Medical Association, Inc., (Hereinafter referred to as 'FMA') and your organization (Hereinafter referred to as 'Licensee').

WHEREAS, the FMA possesses lists of members, available in Electronic Data File Format and/or pressure sensitive labels depending on the quantity ONLY.

WHEREAS, Licensee wishes to avail itself to such electronic data files and/or pressure sensitive labels.

NOW, THEREFORE, and in consideration of the mutual covenants herein, the parties agree as follows:
1. Licensee shall utilize the electronic data file and/or pressure sensitive labels for its own internal purposes.
2. Licensee may not reproduce market or otherwise distribute said electronic data file and/or pressure sensitive labels without the prior expressed written consent of the FMA.
3. Licensee acknowledges that any electronic data file and/or pressure sensitive labels are the exclusive property of the FMA and agrees to indemnify and hold harmless the FMA for the diminution of value of said electronic data file and/or pressure sensitive labels caused by Licensee's unauthorized use of said electronic data file and/or pressure sensitive labels and for damages resulting from and including but not limited to, any business opportunity lost to the FMA as a result of Licensee's unauthorized use of said electronic data file and/or pressure sensitive labels.
4. This Agreement shall be governed and construed according to the laws for the State of Florida.
5. This Agreement is not assignable by either party without the other parties' prior written consent, which consent shall not be unreasonably withheld.
6. The parties agree that no waiver of any breach, privilege or provision shall be construed as waiver of any future breach, privilege or provision.
7. No amendment to this Agreement shall be effected unless it is in writing and signed by the authorized corporate officers of both parties.
8. This agreement constitutes the entire agreement between the parties concerning the subject matter herein, and all prior representations, statements, negotiations, and undertakings are superseded or restated herein. There are no oral agreements.
9. This Agreement is nonexclusive.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day, month, and year written above.
  
  
Date
Name of Organization
Contact
Address
City
  		State Zip
 
Phone Fax
E-mail Address 
Please provide Florida State Sales Tax Exemption Number if Applicable 
Please choose format:  
Select Criteria 
Entire Membership of Florida Medical Association
County

(To select multiple counties, please hold down your CTRL key while choosing counties)
Specialty

(To select multiple specialties, please hold down your CTRL key while choosing specialties. Charge for each additional specialty is $20.)
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Shipping Information
Date Desired for Shipment 
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Payment:
The minimum charge for any list is $50.00 There is a $15.00 processing fee for ALL orders. Orders must be paid in full prior to processing. Payment can be made via check, money order, MasterCard, Visa or American Express. Each record processed costs $0.08 (e.g., 100 names will cost $8.00).
By checking this box, you are verifying that you have read the license agreement above.