VOSH International
Application for New State or Regional VOSH Chapter
This form is to be used to apply to form a new VOSH state or regional chapter. Questions should be directed to V/I Executive Director Natalie Venezia: venezia@vosh.org. If you wish to form a school chapter, please see the V/I website at http://vosh.org/get-involved/find-a-school-svosh-chapter/
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NAME OF PERSON MAKING APPLICATION ON BEHALF OF PROPOSED CHAPTER
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First
Last
EMAIL OF PERSON MAKING APPLICATION
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ADDRESS OF PERSON MAKING APPLICATION
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
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Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Democratic Republic of the Congo
Republic of the Congo
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Curacao
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
We are making this application for a PROVISIONAL CHAPTER to be known as VOSH- (Please choose a name of geographical region from which membership will be drawn ie: a state or a region based on the location of where the chapter is incorporated, not based on the location of the people to be served)
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WE UNDERSTAND WE HAVE THE OBLIGATION TO FORM A NOT-FOR--PROFIT CORPORATION TO SERVE AS THE OPERATING ENTITY FOR THE CHAPTER FOR WHICH EVENTUAL RECOGNITION IS SOUGHT. ATTACHED IS A COPY OF THE FILED ARTICLES OF INCORPORTION OF THE PROPOSED CHAPTER AS A NOT-FOR-PROFIT CORPORATION IN MY STATE.
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ATTACHED IS A COPY OF ANY CURRENT DOCUMENT INDICATING THE NON-PROFIT CORPORATION’S TAXPAYER IDENTIFICATION NUMBER AS AWARDED BY THE INTERNAL REVENUE SERVICE
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ATTACHED IS A COPY OF THE CURRENT BYLAWS OF THE NOT-FOR-PROFIT CORPORATION FORMED FOR THE PROPOSED CHAPTER
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ATTACHED IS COPY OF A RECENT STATEMENT FOR THE CURRENT CHECKING ACCOUNT FOR THE PROPOSED CHAPTER’S OPERATING FUNDS
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WE UNDERSTAND THAT WE MUST PROVIDE A LIST OF THE PROVISIONAL CHAPTER LEADERSHIP, WHICH INCLUDES A PRESIDENT, VICE-PRESIDENT, SECRETARY AND TREASURER. THE INITIAL OFFICERS OF THE PROPOSED PROVISIONAL CHAPTER ARE: (OR ATTACH A FILE BELOW)
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OR DOWNLOAD A LIST OF THE PROVISIONAL CHAPTER LEADERSHIP
PROVISIONAL CHAPTER MEMBERSHIP:
WE UNDERSTAND THAT THE NUMBER OF PRESENT MEMBERS OF THE PROPOSED PROVISIONAL CHAPTER MUST BE AT LEAST SEVEN, OF WHOM AT LEAST ONE IS A DULY LICENSED OPTOMETRIST OR OPHTHALMOLOGIST PRACTICING IN THE GEOGRAPHICAL REGION FROM WHICH MEMBERSHIP WILL BE DRAWN. BELOW ARE THOSE INDIVIDUALS' NAME, ADDRESS, PHONE AND EMAIL (OR ATTACH A FILE BELOW)
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OR DOWNLOAD A LIST OF PROVISIONAL CHAPTER MEMBERS
THE PROPOSED PROVISIONAL CHAPTER’S INITIAL MISSION OR PROJECT DURING ITS FIRST YEAR OF PROVISIONAL AFFILIATION WITH VOSH/INTERNATIONAL WILL BE CONDUCTED WITH THE ADVICE AND COUNSEL OF AN ADVISING CHAPTER, IDENTIFIED BELOW. OUR CONTACT PERSON WITH THAT CHAPTER IS:
(PLEASE PROVIDE VOSH CHAPTER NAME, INDIVIDUAL'S NAME, ADDRESS, PHONE, EMAIL)
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WE PROPOSE THE FOLLOWING MISSION OR PROJECT AS OUR INITIAL FIRST YEAR VOSH EFFORT (PLEASE PROVIDE AS MANY DETAILS AS POSSIBLE):
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If granted Provisional Chapter status by VOSH-International, the Chapter agrees to accept and govern itself and its activities by the principles, rUles and regulations found in the VOSH/IINTERNATIONAL Constitution, Bylaws, and directives of the VOSH/INTERNATIONAL Executive Board and Board of Directors.
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EXCERPTS FROM BEST PRACTICE “PROTOCOLS” RATIFIED DEC 14, 2011*
A. Each State/Region Chapter shall pay $100/year membership dues no earlier than October1st and no later than December 31st.
B. Each State/Region Chapter is encouraged to make an annual per capita donation to VOSH/International on behalf of each member.
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WE AGREE
WE DONT AGREE
PLEASE SUBMIT AN APPLICATION FEE OF $100.
$
Dollars
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Cents
If another entity is paying your application fee, please explain.
Please note that photos may be taken of you as a volunteer of VOSH and may be used to promote VOSH.
THE AFORMENTIONED HUMANITARIAN HEREBY APPLIES FOR AFFILIATION TO WITH VOSH/INTERNATIONAL AS A PROVISIONAL CHAPTER. BY SUBMITTING THIS APPLICATION, WE CERTIFY THAT WE HAVE READ AND UNDERSTAND ARTICLE VI OF THE VOSH/INTERNATIONAL BYLAWS AND THE BEST PRACTICES PROTOCOLS FOR CHAPTERS, AND ACCEPT THE OBLIGATIONS IMPOSED THEREIN. Respectfully submitted on behalf of the above named prospective officers:
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