Membership Summary Sheet and Payment Form

Alumni Chapter Name: Affiliate Number:

Alumni Chapter Address:

Alumni Chapter Contact Person:

Total Number of members paying ______at $3.00 per member. $______Total Amount Annual State dues: for Annual State Dues

Total Number of members paying ______at $10.00 per member. $______Total Amount Annual National dues: for Annual National Dues

Total Number of members paying ______at $50.00 per member. $______Total Amount State Life membership dues: for State Life Dues ** Please list names on back**

Total Number of members paying ______at $160.00 per member. $______Total Amount National Life membership dues: for National Life Dues ** Please list names on back**

Total Number of Subscriptions to ______at $2.00 per annual $______Total Amount FFA New Horizons member. for New Horizons Subscriptions

Grand Total Membership and Magazine $______Subscriptions

Please make checks payable to: North Carolina FFA Alumni Association NCSU Campus Box 7654 Raleigh, NC 27695-7654 Phone: 919-515-4206 Fax: 919-513-3201 STATE LIFE MEMBERSHIP Please list names of those paying State Life Dues

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NATIONAL LIFE MEMBERSHIP Please list names of those paying National Life Dues

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10. Alumni Chapter Leadership Form

Alumni Chapter Name: Affiliate Number:

Alumni Chapter Address:

Alumni Chapter Contact Person:

Please list your FFA Alumni chapter officers

______, President

______, Vice President

______, Secretary

______, Treasurer

______, Council Member

______, Council Member

______, Council Member

______, Council Member

______, Council Member

______, Other Officer ______

______, Other Officer ______

______, Other Officer ______

When does the term of service expire for these officers? ______Date