Check-Off Request
Please fill in the following information to receive check-off dollars
Requesting State *
Your answer
Quarter Ending *
Your answer
State Officer Section Officers name, address, phone number and email address are required.
Not every state association has each officer position so place an NA in the fields that are not applicable since each field is a required field.
President
Please fill in the following information for the president.
President First & Last Name *
Your answer
Email *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Phone Number *
Your answer
Vice President
Please fill in the following information for the vice president
VP and Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Email Address *
Your answer
Phone Address *
Your answer
Treasurer
Please fill in the following information for the treasurer
Treasure First & Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Secretary
Please fill in the following information for the secretary
Secretary First & Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Other
List additional people here. Please include names, address, phone and email for everyone listed.
Your answer
Please send the Check-Off Dollars for our state to:
Name to send dollars to *
Your answer
Email *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Additional Information.
Would you like to submit publication email addresses that you would like us to include in our press release list? Please provide them here.
Your answer
Your website address:
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Your Facebook page URL
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