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Region IV Chapter Visit Request
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Region IV Chapter Visit Request
Questions can be directed toward:
Mariya Kim, Region IV Membership Chair at
[email protected]
Applicant Name & Title:
*
Mariya Kim - Region IV Membership Chair
Main Chapter Contact & Name of Chapter:
*
Main Chapter Contact: ________________________________________________ a. Chapter Position ______________________________________________ b. Email Address ________________________________________________ c. Cell Phone Number ___________________________________________ Name of Chapter: ________________________________________________ a. Chapter Name ________________________________________________ b. Chapter Address (Street, City, State, Country) __________________
How would you classify you Chapter?
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Defunct (Being revitalized)
Inactive
Active
(1) Do you have a preference on who visits your Chapter(List top 3)? (2) List your preferred Top 3 dates for the visit, and note if there is a particular event on the date(s) so that visits can be prioritized. (3) Is there something specific that you want to discuss during this visit?
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Type of Visit:
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Membership Recruitment Help
Program Implementation
Leadership Development
Need Generic Support
Submit