Date __________________________
Chapter Address: Fill out ONLY if all officers are to receive chapter mail at a permanent address. If this space is used, do not fill out resident addresses for each officer; give only their names, telephone, fax, and e-mail numbers.
Chapter Street Address: _________________________________________________
Chapter City/State/ZIP: _________________________________________________
Web Site ________________________________________________________________
************************************************************
President - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Secretary - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Treasurer - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
*Membership Chairman - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
*NOTE: Please complete the Membership Chairman area, even if you do not elect a chairman. We must have someone responsible for accepting membership data.
Education Chairman - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Newsletter Editor - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Vice President - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Region Representative - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Program Chairman - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Additional Officers:
Title: ____________________ - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Title: ____________________ - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Title: ____________________ - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Title: ____________________ - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Title: ____________________ - ID # ______
Name _________________________________________________
Street Address _________________________________________________
City/State/ZIP _________________________________________________
Telephone ____________ FAX ____________ E-mail _________________
Send a copy of this completed form to the following immediately after election:
4/2006
SECTION VII - F