Chapter - Intent to Form Letter

Letter of Intent to Form an IASP Chapter
Thank you for your interest in becoming an IASP Chapter. Please fill out this form in its entirety for considerations. Questions concerning the application may be directed to IASPinfo@strategyassociation.org.

*Please note, all proposed chapter officers must be members in good standing of IASP. Please ensure memberships are up-to-date or JOIN HERE before completing this form.
Authorized Agent Information
Note: all the official communications between IASP and the applicant chapter will be with the person(s) named as the authorized agent for the applicant chapter (or proposed Chapter President, if the same) and an official representative of the IASP as determined by the IASP Executive Committee.
Authorized Agent Name*

PrefixFirst NameLast NameSuffix
Authorized Agent Role (position at the Chapter)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Country CodeArea CodePhone Number
Fax Number

Country CodeArea CodePhone Number
Email*
example@example.com
Chapter President (if different than above)

PrefixFirst NameLast NameSuffix
Chapter Location
Please indicate below where the governing body of the chapter applicant (or a delegated authority for the group) has determined that it wishes to serve.
Is the proposed chapter located in the U.S.?*
Provide below a clear description of the geographical boundaries of the proposed Chapter.

Note: The area shall not conflict with the area of any existing IASP Chapter. In the event of a conflict it must be resolved by the IASP through (1) a revision of the area described in the petition to eliminate the conflict, or (2) written consent of the existing Chapter with which there is a conflict to a revision of its area of jurisdiction, together with a description of the area as it would be established after revision.
Geographical Boundaries *
Proposed Chapter Name*
If applying for an International Chapter, please describe in the space below the type of certificate of incorporation or similar organization (e.g., non-profit or volunteer organization) that will be pursued to legally incorporate as an IASP International Chapter Affiliate in the specified territory. Please also include the estimated steps and costs to incorporate, if known.
Incorporation Information
CHAPTER OFFICERS

Proposed Chapter Officers must be members in good standing of IASP. Please visit the IASP Membership Page linked above to join.

	Chapter Officer
Full Name
Email Address

Board Position

	Chapter Officer
Full Name
Email Address

Board Position

	Chapter Officer
Full Name
Email Address

Board Position
Do you have additional officers to add?

Board Position
Do you have additional officers to add?

Board Position
CHAPTER MEMBERS
List the names, affiliations, and email addresses of at least seven additional persons (current IASP Members) who propose to form the Chapter and who are working within the described geographic area.

	Member Contact Information
Name
Email
Phone
Chapter Role

	Member Contact Information
Name
Email
Phone
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

	Member Information
Name
Email
Organization
Chapter Role

Signature of Authorized Agent for Applicant Chapter
By checking the below boxes and dating this form, the authorized agent for the Applicant Chapter acknowledges the following:
Type a question

The proposed geographic territory is subject to modification by IASP (at any time) following consultation with the chapter president.This Letter of Intent represents the intention and commitment of the above named Applicant Chapter to apply for status as an IASP Chapter.The governing body of the Applicant Chapter has reviewed the IASP Chapter Start Up Guide, the relevant Chapter Agreement, and IASP Chapter Policies.Represent that this letter of intent is true and accurate and that I am authorized to sign this Letter of Intent on the behalf of the Applicant Chapter.
Today's Date

MonthDayYear
Date
Should be Empty:

Letter of Intent to Form an IASP Chapter

Authorized Agent Information

Chapter Location

CHAPTER OFFICERS

CHAPTER MEMBERS

Signature of Authorized Agent for Applicant Chapter