Charter Applicaon
This application is for an (please check one)
o Alpha (Elementary) o Junior Level (Middle School/Junior High) o Octagon Level (High School)
Club name as it will appear on charter and bylaws: __________________________________________
City: ________________________ State/Prov: ____ ZIP/Postal Code: __________ Country: _______
Amount of Annual Dues: $ ________________________________________________________________
Date of Organizational Meeting: ___________________________________________________________
Number of Charter Members: _____________________________________________________________
Scheduled Date of Charter Presentation: ___________________________________________________
Location of Meetings: ____________________________________________________________________
Sponsored by: __________________________________________________________________________
District Name: ______________________________________________ Club No. ___________________
Zone (if applicable): ______________________________________________________________________
We certify that the organizational meeting of the above Club was conducted on the date specied.
The registration fee, enrollment fee and membership fee are enclosed with this application.
Also enclosed are the ofcer information sheet, membership roster, and signed Club Bylaws.
(Authorized Ofcial)
(Junior Optimist President Signature)
$ Enrollment Fee
$ Registration Fee
$ Membership Fee ( _____ x $_____ )
$ Total Enclosed (U.S. or Canadian
Return to:
Junior Optimist Department
Optimist International
4494 Lindell Boulevard
St. Louis, Missouri 63108
Fax: (314) 371-6006
Optimist International Canada
5205 Blvd. Metropolitain Est.,
Suite 200 Montréal, (Québec)
H1R 1Z7
Fax: (514) 721-1104
Enrollment and Registration Fee
Membership Fee
Ofcer Information Sheet
Membership Roster
Signed Club Bylaws
New Club Form
click to sign
click to edit