Chapter Dues Exemption Request Form
Please complete this form to request exemption from chapter dues. Members who have raised $1,000 or more are eligible for chapter dues exemption. Attach all necessary documentation as proof of funds raised.
Member Information
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fundraising Details
Total Amount Raised
*
Date of Fundraising Completion
*
-
Month
-
Day
Year
Date
Description of Fundraising Activities:
*
Please describe the events or activities you organized to raise funds
Which programs or initiatives would you like your donation to support?
Please Select
ACHIEVEMENT WEEK
SCHOLARSHIP
TALENT HUNT PROGRAM
RECLAMATION and RETENTION
HEALTH INITIATIVES
MEMORIAL SERVICE
SOCIAL ACTION
NAACP
STEM
FATHERHOOD AND MENTORING
VOTER REGISTRATION, EDUCATION & MOBILIZATION
OTHER
Other
*
Proof of Funds Raised (Select all that apply)
*
Donation Receipts
Bank Deposit Slips
Confirmation Emails
Other
Supporting Documents
*
Browse Files
Drag and drop files here
Choose a file
Please attach copies of all documents as evidence of funds raised
Cancel
of
Authorization
*
I hereby certify that the information provided is accurate and that the attached documentation is authentic.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: