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Check-Off Request
Please fill in the following information to receive check-off dollars
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* Indicates required question
Requesting State
*
Your answer
Quarter Ending
*
Your answer
Designate if there are no changes this quarter.
If there are no changes in officers then please designate this by checking the checkbox below and move on to the
"Send Check-off Dollars To" section
.
There are no changes in officers
Please only fill in the officers that have changed.
State Officer Section Officers name, address, phone number and email address are required.
President
Please fill in the following information for the president.
President First & Last Name
Your answer
Email
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip code
Your answer
Phone Number
Your answer
Vice President
Please fill in the following information for the vice president
VP and Last Name
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Email Address
Your answer
Phone Address
Your answer
Treasurer
Please fill in the following information for the treasurer
Treasure First & Last Name
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Email Address
Your answer
Phone Number
Your answer
Secretary
Please fill in the following information for the secretary
Secretary First & Last Name
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Email Address
Your answer
Phone Number
Your answer
Other
Junior Advisor(s)
List additional people here. Please include names, address, phone and email for everyone listed.
Your answer
Please send the Check-Off Dollars for our state to:
Name to send dollars to
*
Your answer
Email
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Additional Information.
Which officer would you like to receive statements from ASA and ASA Publication, Inc.?
*
President
Vice President
Secretary
Treasurer
Would you like to submit publication email addresses that you would like us to include in our press release list? Please provide them here.
Your answer
Your website address:
Your answer
Your Facebook page URL
Your answer
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