Clic126AmA

Member Application

Date ________________ Sex o male o female Prefix o Mr. o Mrs. o Ms. O Miss

First name ________________________________________ MI _______ Last name _________________________

Suffix (Jr., III) ________ Nickname ______________________________________ Birthday ___________

Spouse's name _____________________________ Birthday ___________ Anniversary _____________

Home address ____________________________________________________________________________________________

City ____________________________________ St ate______ Zip ________ –

Occupation _________________________________ Employer ______________________________________________

Business address ___________________________________________________________________________________________

City ___________________________________ St ate______ Zip ___________–

preferred mailing address o home o business Home ph one__________________

Business phone __ ___________Ext______ Fax _________________

e-mail ____________________________ mobile ph one________________________

Sponsor's Name ____________________________________________

Have you been an Ambuc member before? o yes o no

To be completed by club secretary

Chapter __________________________________ Chapter Number

Type of activity o new member o reinstated member o transfer from chapter ________________________________

o also a dual member* of chapter ______________________________________________

*dual membership does not have a sponsor or receive Big Hat credit

Type of membership o active o associate o honorary o emeritus o military o life o senior

Sponsor's ID no. Sponsor's chapter ________________________________________

Membership effective date: forms received after closing date cannot be made retroactive

o First quarter (received by Resource Center June 1 - Sept 10)

o Second quarter (received by Resource Center Sept 1 - Dec 10 o Branding Time Credit Oct 1 - Dec 10 )

o Third quarter (received by Resource Center Dec 1 - March 10)

o Fourth quarter (received by Resource Center March 1 - June 10 o Spring Round Up Credit March 1 - April 30)

IMPORTANT! Immediately distribute the completed application to the AMBUCS Resource Center and chapter officers.

Your prompt action will ensure the new member receives his/her orientation materials and magazine subscription,

and will demonstrate that he/she is enthusiastically welcomed.