PLEASE PRINT

Name _____________________________________________ Date __________

Member Code _____________________________ Phone (______)___________

Street Address _____________________________________________________

City, State, Zip _____________________________________________________

I request transfer of my Membership:

From Chapter:  ________________________________ in ___________________
                                Chapter Name and Number                        State

To Chapter:     Longmont Chapter #16                          in Longmont, Colorado

Transferring Member's Signature: ________________________________________

NOTE: Approval of this transfer is required by the receiving Chapter under Article 11, Section 11.10 of the National Constitution and By-Laws.

Approved ___        Rejected ___

__________________________        _________________________________________________
                Date                                                 Signature and Title of Chapter Officer