Change Request Form
National Headquarters
8405 Greensboro Drive Suite 800
McLean, VA 22102
1-800-326-2163 ¨ FAX 703-506-3266
____________________________________ Chapter No.This Change Request Form must be received at National Headquarters by June 1 to become effective for the following fiscal year beginning July 1. Any changes which shall result from this reclassification shall become effective within the next fiscal year.
Name: ____________________________ Signature: _________________________ Date: _____________
(Provide name currently on National Headquarters records).
NAME/ADDRESS CHANGE (Check preferred mailing address):
Name _______________________________________________________ Telephone Number
Home Address ________________________________________________ 9; (______)______________
_____________________________________________________________ 9; (______)_____________
Business Address ______________________________________________ (______)______________
_____________________________________________________________ 9; (_______)_____________
_____________________________________________________________ #9;
STATUS CHANGE
___ TRANSFER From: ________________________ Chapter to: ____________________ Chapter
(Current Chapter & National dues must be paid to the chapter of which the member was affiliated on June 30 of the previous year before the transfer can be processed. Upon processing of transfer, the individual immediately becomes a member of the new chapter.)
___ INACTIVE (Remove from member list) ___________________________________________________ #9; #9; (Reason for removal)
MEMBERSHIP CLASSIFICATION CHANGE
REASON
o Obtained Degree: Major ____________ Date _________
o Based on work experience
o Dropped Membership in AWSCPA
o Joined AWSCPA
o Based on age and years of membership
THIS SECTION FOR CHAPTER USE ONLY
Date of Chapter Board Action: _______________ ______________________________________________
Signature of Membership Chair (& print name)
Send Original to Headquarters, make a copy for the chapter files
.