Club Name:                                          

Effective Date:                                        

Today's Date:                                        

Submitted by:                                      

Your Phone:                                              (Must be in this format ###-###-####)

Your e-mail address:                            

OFFICERS

Date new officer(s) assume duties:

Number of members:   

Fiscal year of club/group begins:      ends:

PRESIDENT

Name:   

Address:   

Telephone:       E-Mail: 

VICE-PRESIDENT

Name:   

Address:   

Telephone:       E-Mail: 

TREASURER

Name:   

Address:   

Telephone:       E-Mail: 

SECRETARY

Name:   

Address:   

Telephone:       E-Mail: 

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