| Name of organization: | |
| Mailing Address: | |
| City: | State: Zip: |
| Any special requirements for membership in your club? |
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| Any club special purposes or goals? | |
| Does your club follow normal elections? | |
| Are your officers elected annually? | |
| Approximate number of years your club has been in existence? |
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| Approximate membership? | |
| How often do you conduct meetings? | |
| Signature and Title: |       Date: |