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Membership Deletion Form 130

Membership Deletion Form 130

Date

Form Completed by

Your Email address

Chapter Name

Chapter Number

Note: to be effective deletions must be reported to the AMBUCS Resource Center before the closing date of the specified quarter (10th of the following month). Deletions received after a quarter's closing date will become effective in the next quarter. Effective Dates: 1st Quarter: June 10th - September 10th 2nd Quarter: September 11th - December 10th 3rd Quarter: December 11th - March 10th 4th Quarter: March 11th - June 10th

Select Quarter Deletion to be Effective

1st quarter June-August
2nd quarter September-November
3rd quarter December-February
4th quarter March-May

Note: Deletions CAN NOT Be Back Dated to a Prior Quarter

Member ID No.

First Name

MIddle Initial

Last Name

Written confirmation will be distributed to the Chapter Secretary and Chapter Treasurer within 10 days.