Fillable optimist international CLUB ROSTER ADJUSTMENTS

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optimist international CLUB ROSTER ADJUSTMENTS

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Country of origin: US
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Section A: Name and Address of New Members
Name_______________________________________________________
Address_____________________________________________________
City _____________________ State/Prov _____ ZIP/Postal code ________
Phone ________________________ E-mail ________________________
Name of Sponsor ________________________ Sponsor # _____________
Is applicant a college Member
Yes No
Was applicant ever a JOI Member
Yes
No
Is applicant a Life Member
Yes No
Transfer
Old Club # ___________
Name_______________________________________________________
Address_____________________________________________________
City _____________________ State/Prov _____ ZIP/Postal code ________
Phone ________________________ E-mail ________________________
Name of Sponsor ________________________ Sponsor # _____________
Is applicant a college Member
Yes No
Was applicant ever a JOI Member
Yes
No
Is applicant a Life Member
Yes No
Transfer
Old Club # ___________
Name_______________________________________________________
Address_____________________________________________________
City _____________________ State/Prov _____ ZIP/Postal code ________
Phone ________________________ E-mail ________________________
Name of Sponsor ________________________ Sponsor # _____________
Is applicant a college Member
Yes No
Was applicant ever a JOI Member
Yes
No
Is applicant a Life Member
Yes No
Transfer
Old Club # ___________
Name_______________________________________________________
Address_____________________________________________________
City _____________________ State/Prov _____ ZIP/Postal code ________
Phone ________________________ E-mail ________________________
Name of Sponsor ________________________ Sponsor # _____________
Is applicant a college Member
Yes No
Was applicant ever a JOI Member
Yes
No
Is applicant a Life Member
Yes No
Transfer
Old Club # ___________
Members cannot be added unless processing fees are paid. Fee is $15.00 (US) or
Canadian dollar equivalent per new Member
Check # ________ Enclosed for __________ (Transfers $5 US or Canadian dollar equivalent)
PLEASE NOTE DISTRIBUTION KEY: U.S. Club CRAs to St. Louis / CANADIAN Club CRAs to St-Leonard
CLUB ROSTER ADJUSTMENTS
Alert! Deletions without additions may affect your awards status! (PLEASE PRINT)
Pres. or S/T_______________________________________________
District # Club #
Club Name
Section B: Members To Be Deleted
Member # Name New Address City State/Prov ZIP/Postal Code
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Member # Name Code
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Member # Name Code
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Section D: Club Officer Changes
For CURRENT Year Officers ONLY
For Address Change Only - Use Section B
Office Member # Club Officer’s Complete Name Home Phone Business Phone
PRES
SEC
TREAS
Signature of President
Phone: B ( ) __________________________
R ( ) _
_______________________________
Signature of Secretary-Treasurer Phone: B ( )__________________________
R( ) ________________________________
White:
Green: Governor Pink: Lieutenant-Governor
Canary: District Secy-Treas. Gold: Club File
Codes 1 - non-payment of dues 3 - deceased
4 - resigned2 - moved
MEM1104 LTR-9216
Section C: Name/Address Changes and Spelling Corrections
Now available online at www.optimist.org
Contact the International Office for password
US - PO Box 500473, St. Louis MO 63150-0473
Fax: 314-371-6006
CANADA - 5205, boul. Metropolitain est, Suite 200 Quebec H1R 1Z7
Télécopieur: 514-721-1104
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optimist international CLUB ROSTER ADJUSTMENTS

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Completed 18 January 2020

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