VOSH International

Date * MM / DD / YYYY
NAME OF PERSON MAKING APPLICATION ON BEHALF OF PROPOSED CHAPTER * First Last
EMAIL OF PERSON MAKING APPLICATION *
ADDRESS OF PERSON MAKING APPLICATION *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code 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) *
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. *
ATTACHED IS A COPY OF ANY CURRENT DOCUMENT INDICATING THE NON-PROFIT CORPORATION’S TAXPAYER IDENTIFICATION NUMBER AS AWARDED BY THE INTERNAL REVENUE SERVICE *
ATTACHED IS A COPY OF THE CURRENT BYLAWS OF THE NOT-FOR-PROFIT CORPORATION FORMED FOR THE PROPOSED CHAPTER *
ATTACHED IS COPY OF A RECENT STATEMENT FOR THE CURRENT CHECKING ACCOUNT FOR THE PROPOSED CHAPTER’S OPERATING FUNDS *
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) *
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) *
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) *
WE PROPOSE THE FOLLOWING MISSION OR PROJECT AS OUR INITIAL FIRST YEAR VOSH EFFORT (PLEASE PROVIDE AS MANY DETAILS AS POSSIBLE): *
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. *
Yes No
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. *
WE AGREE WE DONT AGREE
PLEASE SUBMIT AN APPLICATION FEE OF $100. $ Dollars . 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: * Title First Last Suffix
Do Not Fill This Out