EmailMe Form - 2012 Social Club Charter Application

Club/Chapter Name *

Contact Person Name *

First Last

Contact Person Phone *

### - ### - ####

Club Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Club Phone

### - ### - ####

Club Email

Club Web Site

Enter information about club members below. Five club members must be listed in addition to the Contact Person (listed above) and Club President.

President

First Last

President
ATVA/AMA Number

Member No. 1

First Last

Member No. 1
ATVA/AMA Number

Member No. 2

First Last

Member No. 2
ATVA/AMA Number

Member No. 3

First Last

Member No. 3
ATVA/AMA Number

Member No. 4

First Last

Member No. 4
ATVA/AMA Number

Member No. 5

First Last

Member No. 5
ATVA/AMA Number

Is your club a member of your district organization?

Yes

No

Is your club incorporated?

Yes

No

What year was your club organized?

If your club donates to charitable organizations, how much did you donate during 2011?

In a few words or sentences, please describe your club's primary activities.

This Club Charter Application is a:

New Application

Renewal

If this is a renewal application, include the club's existing Charter No. here: