EXPENSES SBA by jolinmilioncherie

VIEWS: 1 PAGES: 19

									January 2011

Dear 2010 Chapter President:

The time has come again to renew your chapter’s charter. We are eager to begin a new year which will
include many exciting offerings, including educational webinars, revisions to several publications (check
our website in spring for more details!) and also the Legal Nurse Consulting Educational and Networking
Forum 2011, taking place Friday, April 1- Saturday, April 2, 2011in Baltimore, Maryland.

Enclosed is the checklist of forms and information to be completed for the 2011 Chapter Charter
Renewal. All Chapter Charter Renewal forms and renewal fees are due by February 18, 2011. Please
note the renewal fee is $200.

As a reminder of some of the benefits chapters receive through AALNC are:
     Directors and Officers Liability Insurance
           o (a $2,500 value per chapter for Directors and Officers Liability)
     Federal Tax Filings done on your behalf
     Governance support (AALNC Director-at-Large/AALNC National Headquarters)
     Membership/Marketing tools

Please make any additions or changes directly on this form and be sure to indicate your officers for 2011.
If you do not indicate any changes, we will conclude that all of the information in the AALNC database is
correct.

Also attached are templates for your financial report forms and chapter membership report form, as well
as the bylaws verification form. Additionally, all report forms are also posted for your convenience on the
Chapter Leaders’ Web page at http://www.aalnc.org/about/chapter_leaders.cfm.

As a reminder, the Chapter Charter Renewal process serves two main purposes. First and foremost,
AALNC Headquarters utilizes the 2010 financial information obtained during this process to file taxes on
your behalf. If your chapter was operational during 2010, you must complete the Charter Renewal
paperwork.

Additionally, the Chapter Charter Renewal process serves to maintain your chapter’s active status. For
this reason, you must return your completed chapter charter renewal form showing your 2011 Chapter
Contact Information and Board of Directors Listing, along with the financial forms, bylaws compliance
form, membership report forms, checklist and payment to AALNC by February 18, 2011. Remember to
keep photocopies for your records.

If you have any questions, please direct them to Kathryn Schafer, AALNC’s Education and
Communications Associate at kathryn.schafer@aalnc.org or 877/402-2562. We look forward to your
participation in another successful year for AALNC and your chapter.

Sincerely,

Kathryn Schafer
AALNC Education and Communications Associate
          2011 CHAPTER CHARTER RENEWAL CHECKLIST

  Please use this checklist to ensure that you complete and include all necessary
           paperwork when returning your Chapter’s Charter Renewal!



 Completed Chapter Charter Renewal Form………. ……………………….                            3-4
    (Including 2010 chapter contact information, officers and website listing)

 Review 2010 Rules and Regulations          ……………………………………..                      5-9

 Completed Affiliate Agreement ……………………………………………....                            10-12


 Completed Verification of Compliance …………………………………. ….                           13


 Completed Financial Report Forms ………………………………………….                             14-16

 Completed Membership Report Form OR Chapter Membership Roster..                17-19

   Charter Renewal Fee
         ($200.00 check made payable to AALNC)



                           Due Date: February 18, 2011
               Mail the completed Chapter Charter Renewal Packet to:
                American Association of Legal Nurse Consultants
                                  401 N. Michigan
                                 Chicago, IL 60611
                               Attn: Kathryn Schafer




                                                                                     2
                          2011 Chapter Charter Renewal
                      American Association of Legal Nurse Consultants
                              401 N Michigan Avenue  Chicago, IL 60611
                                   T 877.402.2562  F 312.673.6655
                                  E info@aalnc.org  www.aalnc.org


      Legal Nurse Consultants of West Virginia Upper Ohio Valley Chapter
Chapter EIN:[330298097]
Charter Number: [51]
REACTIVATION NOTICE                           Due Date: February 18, 2011

2011 Chapter Charter Reactivation Fee                                           $200.00
Instructions: Copy this form for your records and return the original with your payment to AALNC. Please
review all of the information on this form for accuracy. Record additions and/or changes directly
on this form. Please PRINT clearly.


Our 2011 Chapter Officers are:
(Please provide a complete roster of your chapter’s Board of Directors. This information will be used to
grant access to the Chapter Leader’s Discussion Group and the Chapter Leader’s Resource Page to the
members of your chapter’s Board of Directors)

President:                                      Director:

President-elect:                                Director:

Treasurer:                                      Director:

Secretary:                                      Director:

Membership Director: _______________________________

Other: ___________________________________________

Other: ___________________________________________

President Email: _____________________________________________________

President Elect Email: _________________________________________________

Membership Director Email: ____________________________________________




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CHAPTER INFORMATION
Please list chapter information as you wish for it to be listed on the AALNC website

Contact Person: ____________________________                 Position: ________________________

Phone # __________________________________                   Fax # __________________________

Address1: _________________________________                  Address2: _______________________

City: ____________________________            State: ________ Zip: _________________________

Email: _____________________________________________________

Alternate Email Contact: _______________________________________

Website: ___________________________________________________


Chapter address to which HQ information and materials should be sent (if different from above):

Contact Person: _____________________________

Address1: __________________________________                 Address2: _______________________

City: _____________________________ State: _________ Zip: ________________________

Email: ________________________________________


View your chapter roster online in the Members Only section at anytime:

Your chapter login is as follows:
ID#: [54386]
Password: [welcome]

Login and update your chapter information, search for members and view AALNC
membership resources and benefits.


Chapter Rosters
Please encourage your members to login to their online records and select their chapter
affiliation. This will ensure that AALNC Headquarters has the most accurate listing of
chapter membership rosters at all times.

We are very excited to have a Chapter Leader’s Discussion Forum available for all chapter leaders. This tool allows
you to communicate with one another more easily.

        If you have any questions please contact Kathryn Schafer at AALNC
       Headquarters. Phone 877/402-2562. Email Kathryn.Schafer@aalnc.org.
                                   THANK YOU!




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                      ASSOCIATION OF LEGAL NURSE CONSULTANTS
                           CHAPTER RULES & REGULATIONS


Chapters of the American Association of Legal Nurse Consultants (AALNC) are authorized by and
accountable to the AALNC Board of Directors. Chapters must be organized and operated in accordance
with the purposes of AALNC, and must comply with the AALNC Chapter Bylaws, the AALNC Chapter
Rules & Regulations, the AALNC Affiliate Agreement and federal guidelines for tax-exempt
organizations. Failure to comply will result in revocation of the chapter’s charter.


I.     Application for charter as an AALNC Chapter
       A.     The following items must be submitted to the AALNC office:
              1.      Chapter Intention Form

               2.      Completed Charter Application Form including the chapter’s current mailing
                       address, EIN, and bank account location

               3.      Completed chapter membership list and a list of chapter officers (including
                       national membership numbers for each). A minimum of eight (8) AALNC
                       members is required to organize and maintain a viable chapter.

               4.      Copy of generic AALNC Chapter Bylaws, modified to reflect the chapter name,
                       location, and configuration of chapter board of directors and nominating
                       committee, as approved by the chapter membership.

               5.      Signed and completed Affiliate Agreement.

               6.      The chapter charter fee of $200 must be paid by a check made payable to
                       American Association of Legal Nurse Consultants and drawn on the chapter’s
                       bank account.


II. Organization of Chapters
      A.      Bylaws
              1. AALNC chapters must adopt a version of the generic AALNC Chapter Bylaws. At
                 any time, amendments and additions to the chapter bylaws must be approved by the
                 National AALNC Board of Directors before they are sent to the chapter membership
                 for approval.

               2. All active and associate chapter members must be members of the national
                  association (AALNC). National membership for those in the sustaining category is
                  optional.

               3. Each chapter must have a board of directors of no fewer than four members. Each
                  chapter chooses the number and titles of its board members, based on its needs and
                  resources, and amends the generic chapter bylaws accordingly. One of the board
                  members must be designated the president of the chapter. Other officers may be the
                  president-elect, secretary or treasurer or secretary/treasurer, or immediate past-president.
                  In addition to the officers, the board must include one or more directors-at-large.



                                                                                                            5
     4. Each chapter determines the size and composition of its nominating committee and
        amends the generic chapter bylaws accordingly. The membership of the nominating
        committee should include elected representatives and may also include at-large
        members or board members appointed by the board of directors.

B.   Chapter Name
     AALNC chapters must choose chapter names that reflect the geographic location of the
     chapter (i.e., Phoenix Chapter, Atlanta Chapter) and is in compliance with the Affiliate
     Agreement Section 1. The name of the chapter will be approved by AALNC during the
     Chapter Charter approval process.

C.   Chapter Operations
        1. Chapters are expected to manage day-to-day operations with minimal support
            from the AALNC office or board of directors. Chapter leaders are encouraged to
            consult with the AALNC staff, officers, and directors, however, for advice on
            organizational challenges.

         2. Chapters must submit annual financial and activity reports to the national office
            no later than January 31. Annual activity reports must conform to the format
            established by AALNC and include changes in officers, program dates and sites,
            and other such data required in the annual report form. Reports must be clear and
            legible, preferably typewritten.

         3. Chapters must inform headquarters immediately of any changes in the chapter’s
            address, officers’ names or addresses, or other contact information.

         4. The national and chapter mailing lists are the property of AALNC. Third parties
            wishing to purchase the mailing list should contact the AALNC office for
            information on list availability.

         5. The chapter must indicate on all correspondence, brochures, and other printed
            materials that it is a chapter of AALNC and not the national organization itself.

         6. Chapters may use the AALNC logo in association with the chapter name.
            Individual members may not use the AALNC logo for their personal use, subject
            to the terms of the Affiliate Agreement Section 3.

         7. Chapters must receive the approval of the national association before affiliating
            with, or establishing liaisons with, any other organization, is in co-sponsorship of
            educational programs.

         8. If a chapter chooses not to offer sustaining memberships, it can otherwise seek
            support from organizations such as law firms through the solicitation of
            sponsorship, advertisements, and exhibits.

         9. Chapters may issue membership cards upon initial membership and when chapter
            membership is renewed.

         10. Chapters shall hold meetings on a periodic basis for the purpose of transacting
             business and presenting educational programs.


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                    11. Chapters shall not participate in, or contribute to, any political campaign on
                        behalf of or in opposition to any candidate for public office. Chapters may inform
                        their membership about developments in healthcare policy and legislation.

III.   Financial Regulations
       A.     Records and Reporting
                     1. Annual financial reports must be submitted to AALNC within thirty (30)
                          days following the end of each fiscal year (i.e., by January 31 for the January
                          1—December 31 fiscal year), using the required format.

                        2. The chapter president or president-elect and the chapter treasurer are the only
                           chapter members who may be authorized to sign checks.

                        3. An audit committee shall be established for the purpose of auditing financial
                           records every two or three years. The audit committee shall be comprised of
                           at least three chapter members or non-members, excluding chapter officers
                           and those involved with chapter finances. A copy of the completed audit
                           committee report must be sent to AALNC upon request.

                        4. Financial records must be kept for a minimum of seven years.

                        5. Chapters must obtain written approval from AALNC before entering into any
                           contract or financial obligation beyond one-year.

                        6. Chapters that acquire office space must carry liability and personal injury
                           insurance of $500,000, naming AALNC as beneficiary.

       B.      Tax ID Number/Tax Filing
               1.     AALNC (including its chapters) is incorporated in the state of Arizona as a non-
                      profit organization under Section 501(c) 6 of the Internal Revenue Code. The
                      AALNC federal identification number is 36-2857977. Each chapter will apply
                      for its own federal identification number.

               2.       AALNC recommends that each chapter contact the Secretary of State or an
                        attorney with experience in the incorporation of non-profit organizations in their
                        state for advice on specific state regulatory and tax requirements.

               3.       Chapters shall make separate applications for state income tax exemptions and
                        shall file tax returns or information with state taxing agencies as determined by
                        their respective state statutes.

               4.       AALNC will make all necessary federal income tax filings on behalf of the
                        chapters. Chapters should forward any requests for filings from any federal
                        agency to the national office.

               5.       Chapters may apply to their local post offices for a bulk mail permit.

       C.      Chapter Revenue
               1.     Chapters may charge member and non-member fees, or ask for contributions, for
                      attending educational meetings.


                                                                                                        7
             2.      Chapters may sell space for educational exhibits at their events. The exhibitors’
                     giveaways should be reviewed to ensure that they do not represent a conflict of
                     interest.

             3.      All income generated by chapters should be related to the chapter’s mission and
                     goals. Business income unrelated to the chapter’s non-profit mission is subject to
                     federal income tax.

             4.      Chapters may accept donations to offset the costs of publishing chapter-related
                     materials such as newsletters and brochures.

      D.     Utilization of Funds
             All chapter funds must be used to further the mission and purposes of AALNC and the
             chapter, as detailed in the bylaws.

      E.     Funding Guidelines
             1.     Chapters may solicit financial support for activities related to legal nursing
                    education. Financial support includes money solicited from private individuals,
                    private foundations, companies, and corporations, and excludes state and federal
                    funding.

             2.      Financial support may be solicited for speaker honoraria, coffee breaks, meals,
                     door prizes, publications, program supplies, scholarships, program and chapter
                     publicity, and educational materials (A/V and printed).

IV.   Educational Guidelines
      The intended audience for all educational programs offered by chapters should be nurses,
      attorneys, insurance companies and others in the medical/legal community.

V.    Annual Renewal of Chapter Charters
      A.     Chapter charters will be renewed annually. AALNC will send chapter charter renewal
             notices to each chapter at least one month prior to the annual renewal date. A chapter’s
             charter will be renewed only if the chapter completes the renewal process and is in
             compliance with the Rules & Regulations for AALNC Chapters and the AALNC Chapter
             Bylaws. Following is a list of the types of items that will be required for renewal:

             1.      Charter renewal form, Affiliate Agreement and annual renewal fee

             2.      Copy of chapter bylaws if they have been revised within the past year

             3.      List of officers (including names, addresses, telephone numbers, and AALNC
                     membership numbers)

             4.      List of members with their AALNC membership numbers

             5.      Annual chapter financial report

             6.      Annual report of the chapter’s educational activities in support of AALNC’s
                     purpose and goals.



                                                                                                     8
        B.      AALNC will declare invalid and decharter any chapter that fails to complete the annual
                renew process.

                1.       A late reminder will be sent to the respective chapter president of any chapter
                         that fails to comply with the renewal process within a period of thirty (30) days
                         of the annual renewal deadline.

                2.       A follow-up call will serve as a final reminder to the respective chapter president
                         of any chapter that fails to comply with the renewal process within a period of
                         sixty (60) days of the annual renewal deadline.

                3.       Any chapter that fails to comply with the renewal process within a period of
                         ninety (90) days of the annual renewal deadline will be declared invalid and
                         automatically dechartered.

4.       If a chapter is dechartered, AALNC will notify the chapter by certified letter and the chapter must
send all meeting minutes, financial records, and remaining treasury funds to the national office.




                                                                                                          9
                                AFFILIATE AGREEMENT

This Agreement is made between the American Association of Legal Nurse
Consultants, (AALNC), a non-profit corporation, and ____________________, a
nonprofit corporation (the “Affiliate”).

1.     GRANT OF CHARTER AND LICENSE

                1.1    Charter. AALNC hereby grants to the Affiliate, and the Affiliate
accepts a charter to be and continue as an affiliate of AALNC. AALNC hereby grants
the Affiliate a license to use the name American Association of Legal Nurse Consultant
or the acronym AALNC as a part of its own name as identified above, subject to the
following terms and conditions, during the terms of this Agreement.

             1.2   Chapter. The Affiliate is authorized to operate in the specific
geographic area identified in Exhibit A.

2.     POLICY MANUAL

            The Affiliate agrees to comply with the terms of the Affiliate policies
adopted by AALNC, as they may be adopted and amended from time to time.

3.     AALNC NAME AND LOGO

              In addition to the use of the AALNC name as specified in Section 1, the
Affiliate may utilize the AALNC name and logo in other instances permitted by AALNC,
in accordance with AALNC policies and guidelines.

4.     SEPARATE ENTITIES

              AALNC and the Affiliate expressly agree that they are, and shall remain,
separate entities and that no partnership or agency is created by virtue of this
Agreement. Neither party shall be authorized to incur any liability, obligation, or
expense on behalf of the other. The Affiliate is not liable or responsible for the debts or
obligations of AALNC and AALNC is not liable for the debts or obligations of the
Affiliate.

5.     TERMINATION OF CHARTER

              Either party may terminate the charter granted to the Affiliate: (a) for any
reason upon sixty (60) days written notice to the other party, and (b) upon ten (10) days
notice to the other party in the event of the other party’s material breach of this
Agreement; provided, an Affiliate may request an opportunity to present an objection to
a proposed termination to the AALNC Board of Directors, in which case the proposed
termination shall not become effective until ratified by the AALNC Board of Directors.




                                                                                         10
Notwithstanding anything in this Agreement to the contrary, upon delivery of certified
letter notice of termination, for any reason and by either party, the Affiliate shall promptly
deliver the following to AALNC’s national office: a current roster of all members of the
Affiliate, including all contact information, to enable AALNC to communicate with such
members; Affiliate meeting minutes; financial records; and remaining treasury funds to
the national office. From and after the date of termination, the Affiliate shall cease to
identify itself as an affiliate of AALNC and may only utilize printed material bearing any
mark of AALNC with AALNC’s specific written permission for post-termination use.


6.     MISCELLANEOUS

              6.1   Controlling Law. This Agreement shall be governed by and
construed in accordance with the laws of the State of Illinois, and venue for any
disputes shall be Chicago, Illinois.

               6.2    Successors and Assigns. This Agreement shall inure to the benefit
of the parties and their successors and assigns. Neither party may sublicense or assign
any of its rights or obligations under this Agreement without the prior written consent of
the other party.

                6.3   Notices. Any notice contemplated by, or made pursuant to, this
Agreement shall be in writing and made by courier, facsimile, or mail addressed or
directed to AALNC at 401 North Michigan Avenue #1900, Chicago, Illinois or the
Affiliate at the address shown with the signature of the Affiliate President. Either party
may change the address for notice by 10 days advance written notice to the other party.

             IN WITNESS WHEREOF, the parties have caused this Agreement to be
executed by their duly authorized representatives, effective as of the date first written
above.

[AFFILIATE]                                American Association of Legal Nurse
                                           Consultants

By __________________________                     By ___________________________

Title ________________________                    Title __________________________

Date ________________________                     Date __________________________

Address______________________

____________________________




                                                                                            11
                                  EXHIBIT A

                      GEOGRAPHIC AREA OF AFFILIATE




Atlanta Chapter
Bay Area of Northern California
Central Virginia
Cleveland/NEO
Columbia South Carolina
Connecticut Chapter
Dallas
Delaware
Denver
Eastern North Carolina
Greater Albuquerque
Greater Augusta
Greater Baltimore
Greater Birmingham
Greater Charlotte
Greater Chicago
Greater Houston
Greater Indianapolis
Greater Jackson/New Orleans
Greater Jacksonville
Greater Orlando
Greater Portland/Valley
Greater Sacramento
Greater Tampa Bay
Little Rock
Nashville
New Jersey Morristown
New York City
Orange County Chapter of Southern California
Philadelphia Chapter
Phoenix
Pittsburgh
Puget Sound
San Diego
South Florida
Southern New England
Southern West Virginia
St. Louis
West Virginia Upper Ohio


                                                     12
                  AALNC 2011 Chapter Charter Renewal
                                 Verification of Compliance

As part of the Chapter Charter Renewal process, please respond to the following statements by
placing an “X” in the appropriate box and filling in the blanks as appropriate:

YES    NO

               Our chapter is in compliance with its approved chapter bylaws. If not, please
               explain.




                                                                             _________________

               We have at least four active (currently practicing legal nurse consulting) AALNC
               members in good standing serving on our chapter’s Board of Directors, with one
               serving as President. All have maintained active membership for at least one
               year.

               If, for any reason, our chapter is unable to follow its bylaws, we agree to notify
               the AALNC headquarters immediately to obtain guidance.

               Our chapter is in compliance with the approved AALNC chapter rules and
               regulations (insert link). If not, please explain.




                                                                             _________________
Chapter Name

Your name and title

Signature                                                            Date

                              Return this completed form to:
               Kathryn Schafer  Education and Communications Associate
                               Kathryn.Schafer@aalnc.org
                  AALNC  401 N. Michigan Avenue  Chicago, IL 60611




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          401 N Michigan Avenue  Chicago, IL 60611  T 877.402.2562  F 312.673.6655
                         Email info@aalnc.org  Website www.aalnc.org




                            CHAPTER FINANCIAL REPORT FORM

               JANUARY 1, 2010 through DECEMBER 31, 2010 (or current date)


CHAPTER NAME:        __________________________________________________________

CHAPTER ADDRESS: __________________________________________________________

                     CITY:_______________________STATE:______ZIP:________

CHAPTER NUMBER:      __________________________________________________________

CHAPTER BANK NAME:_________________________________________________________

CHAPTER BANK BRANCH/ADDRESS: ____________________________________________

_____________________________________________________________________________

CHAPTER TREASURER:________________________________________________________

PHONE:               __________________________________________________________




      TOTAL REVENUE:        _________________________ (D) See following pages

      TOTAL EXPENSES:       _________________________ (E) See following pages

      BALANCE:              _________________________ (J) See following pages




Treasurer’s Signature __________________________________________

Date___________________________________




                                                                                        14
                   AMERICAN ASSOCIATION OF LEGAL NURSE CONSULTANTS

                                        CHAPTER REVENUES

              Chapter:                __________________________________________

                   Year:            JANUARY 1, 2010 through DECEMBER 31, 2010




Income from Membership Dues:

                               Number                Dues Amount        Total Income

Active - New                   __________            __________         __________
Active - Renewal               __________            __________         __________
Associate - New                __________            __________         __________
Associate - Renewal            __________            __________         __________
Sustaining - New               __________            __________         __________
Sustaining - Renewal           __________            __________         __________

TOTALS                         __________                               __________ (A)

Other Income:

Educational Program Registrations                                       __________
Sponsors/Donations                                                      __________
Miscellaneous                                                           __________

OTHER INCOME TOTAL                                                      __________ (B)

Interest Income:                                                        __________(C)



TOTAL REVENUE                                                           __________(D)
                                                                        (D)=(A)+(B)+(C)




                                                                                          15
                    AMERICAN ASSOCIATION OF LEGAL NURSE CONSULTANTS

                                              EXPENSES

              Chapter:                __________________________________________

                   Year:           JANUARY 1, 2010 through DECEMBER 31, 2010




                                                                SUMMARY TOTALS

Accounting Services                                             ___________________
Administrative                                                  ___________________
Advertising                                                     ___________________
Bank Charges                                                    ___________________
Chapter Charter Fee                                             ___________________
Conference Calls                                                ___________________
Duplicating                                                     ___________________
Facilities (Meeting Space)                                      ___________________
Food and Beverage                                               ___________________
Honoraria                                                       ___________________
Miscellaneous                                                   ___________________
Office Supplies                                                 ___________________
Postage                                                         ___________________
Printing                                                        ___________________
Secretarial                                                     ___________________
Special Events                                                  ___________________
Telephone                                                       ___________________
Travel                                                          ___________________
Unclassified                                                    ___________________

TOTAL EXPENSES                                                  ___________________ (E)

Revenue over/under Expense                                      ___________________ (F)
                                                                (F) = (D) - (E)

Cash at Beginning of Year                                       ___________________ (G)

Other:

         Assets Purchased                                       ___________________ (H)
         Other Adjustments                                      ___________________ (I)

Cash at End of Year*                                            ___________________ (J)
                                                                (J)=(F)+(G)-(H)+/-(I)

*This balance should have a bank reconciliation or bank statement to support the ending cash position.




                                                                                                         16
              American Association of Legal Nurse Consultants

                   2011 CHAPTER MEMBERSHIP REPORT FORM

Please provide a current list of all your chapter’s members by listing them below or
attaching a copy of your chapter’s membership list. The purpose of providing the list is
to ensure that all chapter members are AALNC members in accordance with AALNC’s
bylaws. Please photocopy this form as needed. Submitting an electronic copy of your
membership roster is also acceptable. Please send this to Kathryn.Schafer@aalnc.org.

CHAPTER NAME:
    ____________________________________________________________


MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________


ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________


MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________


ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________




                                                                                      17
MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________


ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________


MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________



MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________


MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________


MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________




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ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________


MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________


ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________

MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________

ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________


MEMBER’S NAME AND NATIONAL ID# -
______________________________________________________________________


ADDRESS/CITY/STATE/ZIP
_________________________________________________________________________________




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