Forest Glen PTA: State By-Laws
The double starred (**) areas are in conformity with the regulations of
Section 501 (c) (3) of the Internal Revenue Code and are required in the bylaws of the state, region(s), councils and local PTA/PTSA units.
The number symbol (#) areas are required in the bylaws of region(s), councils and local PTA/PTSA units of the Illinois PTA.
Constituent association refers to all associations in membership with the Illinois PTA, including region(s), councils and local PTA/PTSA units.
ARTICLE I - NAME
The name of this association is the Forest Glen Elementary School Parent-Teacher Association (Forest Glen PTA) or Parent-Teacher-Student Association PTSA (PTSA) of Glen Ellyn. It is a local PTA (or PTSA) unit organized under the authority of the Illinois Congress of Parents and Teachers (Illinois PTA), a branch of the National Congress of Parents and Teachers (National PTA). These bylaws shall be deemed to be a part of the Articles of Organization (This PTA is incorporated under the laws of the State of Illinois.)
** ARTICLE II - ARTICLES OF ORGANIZATION
The articles of organization of this local PTA/PTSA unit include (a) the bylaws of such association and (b) the certificate of incorporation or articles of incorporation of such association (in cases in which the association is a corporation) or the articles of organization by whatever name (in cases in which the association exists as an unincorporated association).
ARTICLE III – PURPOSES
The Purposes of the Illinois PTA and the Forest Glen PTA, in common with the purposes of National PTA are:
a. To promote the welfare of children and youth in home, school, places of worship, and throughout the community.
b. To advocate for laws that further the education, health, welfare and safety of children and youth.
c. To raise the standards of home life.
d. To advocate for fiscal responsibility regarding public tax dollars in public education funding;
e. To promote the collaboration and engagement of families and educators in the education of children and youth; and
f. To engage the public in united efforts to secure the physical, mental, emotional, spiritual, and social well-being of all children and youth.
The Purposes of the Illinois PTA and Forest Glen) PTA/PTSA are promoted through an educational program directed toward parents, teachers, and the general public; are developed through conferences, committees, projects and programs; and are governed and qualified by the basic policies set forth in Article IV.
The association is organized exclusively for the charitable, scientific, literary, or educational purposes within the meaning of Section 501 (c)(3) of the Internal Revenue Code or corresponding section of any future federal tax code (hereinafter "Internal Revenue Code").
ARTICLE IV - BASIC POLICIES
The following are basic policies of the Forest Glen PTA/PTSA in common with those of National PTA and Illinois PTA:
**a. The association shall be noncommercial, nonsectarian, and nonpartisan.
**b. The association or members in their official capacities shall not endorse a commercial entity or engage in activities not related to promoting the Purposes of the association.
**c. The association or members in their official capacities shall not - directly or indirectly – participate or intervene (in any way, including the publishing or distributing of statements) in any political campaign on behalf of or in opposition to any candidate for public office; or devote more than an insubstantial part of its activities to attempting to influence legislation by propaganda or otherwise.
d. The association shall work with the schools to provide quality education for all children and youth and shall seek to participate in the decision-making process establishing school policy, recognizing that the legal responsibility to make decisions has been delegated by the people to boards of education, state education authorities, and local education authorities.
#e. The Illinois PTA or any of its divisions may cooperate with organizations and agencies concerned with child welfare, but a PTA/PTSA representative shall make no commitments as an individual that bind the group represented.
**f. No part of the net earnings of the association shall inure to the benefit of or be distributable to its members, directors, trustees, officers, or other private individuals except that the association shall be authorized and empowered to pay reasonable compensation for services rendered and to make payments and distributions in furtherance of the purposes set forth in the ARTICLE—PURPOSES as contained herein.
**g. Notwithstanding any other provision of these articles, the association shall not carry on any other activities not permitted to be carried on (i) by an organization exempt from federal income tax under Section 501(c)(3) of the Internal Revenue Code or (ii) by an organization, contributions to which are deductible under Section 170(c)(2) of the Internal Revenue Code.
**h. Upon the dissolution of the association, after paying or adequately providing for the debts and obligations of the association the remaining assets shall be distributed to one or more nonprofit funds, foundations, or organizations which have established their tax-exempt status under Section 501(c)(3) of the Internal Revenue Code. Upon dissolution and withdrawal of the charter, each local PTA/PTSA unit shall be required to follow procedures as directed in the ARTICLE— RELATIONSHIP WITH NATIONAL PTA AND ILLINOIS PTA as contained herein.
ARTICLE V - MEMBERSHIP AND DUES
Every individual who is a member of a local PTA/PTSA unit is, by virtue of that fact, a member of National PTA and of the Illinois PTA by which a local PTA/PTSA unit is chartered and is entitled to all the benefits of membership.
Membership in each local PTA/PTSA unit shall be made available by the local PTA/PTSA unit to all who believe in the Mission and Vision statements of National PTA and the Purposes of Illinois PTA inclusively.
Each local PTA/PTSA unit shall conduct an annual enrollment of members but may admit individuals to membership at any time.
a. Every local unit will establish a membership year.
b. The membership year of the Forest Glen PTA/PTSA shall begin July 1and end on June 30.
c. Persons who join during the membership year shall pay dues for that year. Persons may hold membership in one (1) or more local PTA/PTSA units upon payment of all-inclusive dues as required by the bylaws of each local PTA/PTSA unit. Newly chartered local PTA/PTSA unit members shall be issued charter membership cards valid for a determined period of time.
d. The membership year of the Illinois PTA shall be July 1 through June 30.
Only members of this local PTA/PTSA unit who have paid dues for the current membership year may participate in the business of this local PTA/PTSA unit.
The privilege of making motions and voting in a local PTA/PTSA unit shall be limited to members of the local PTA/PTSA unit.
Only a dues paying member of a local PTA/PTSA unit may be eligible for election or appointment to office or chairmanship in the Illinois PTA or any of its divisions.
No person shall hold an elected or appointed position in any local PTA/PTSA unit who is not a member in good standing.
Each member of a local PTA/PTSA unit shall pay annual dues to said association as may be prescribed by the association. The amount of dues shall include the portion payable to the Illinois PTA (the "state portion") and the portion payable to National PTA (the "national portion").
a. The national portion of each member's dues shall be determined by the delegates to the National PTA annual convention.
#b. The amount of the state portion of each member’s dues shall be determined by the Illinois PTA. The annual dues to the Illinois PTA shall be two dollars ($2.00) per capita for every member of each local PTA unit.
c. The amount of the local membership dues shall be determined by the members of the local PTA/PTSA unit.
#a. The state and national portions of the dues paid by each member of a local PTA/PTSA unit shall be set aside by the local PTA/PTSA unit and remitted to the Illinois PTA through channels and at times as the state PTA bylaws may provide. The Illinois PTA shall remit to National PTA the amount of the national portion of dues paid by all members of local PTA/PTSA units in its area.
#b. The initial state and national portion of the dues paid by each member to a local PTA/PTSA unit shall be set aside by the local PTA/PTSA unit and remitted to the Illinois PTA postmarked no later than October 1. Dues should be submitted monthly thereafter.
a. A local PTA/PTSA unit shall be considered delinquent if by December 31 it has failed to send to the Illinois PTA the state and national portion of dues paid by no less than twenty-five (25) individual members, or no less than ten (10) individual members for a new local PTA/PTSA unit or for an existing local PTA/PTSA unit where the school enrollment is less than one hundred seventy five (175) students.
b. A local PTA/PTSA unit not affiliated with a school shall be considered delinquent if by December 31 it has failed to send to the Illinois PTA the state and national portions of dues paid by no less than ten (10) individual members.
c. Local PTA/PTSA units which fail to send to the state office of the Illinois PTA by June 30 the national and state portions of dues paid by individual members shall be discontinued as local PTA/PTSA units and their charters shall be withdrawn, as provided in the Article on Relationship with National PTA and Illinois PTA herein.
d. Reinstatement procedures and reinstatement fees shall be in such manner as prescribed by the state board of directors.
ARTICLE VI - OFFICERS AND THEIR ELECTION
Each officer or board member of a local PTA/PTSA unit shall be a member of the local PTA/PTSA unit.
a. The officers of this association shall be one (1) president, (optional two (2) co-presidents), three (3) vice presidents, (including one (1) vice president of communications), one (1) secretary, one (1) treasurer, and one (1) co-treasurer.
b. Officers shall be elected by ballot annually at the April or May meeting. However, if there is only one (1) candidate for any office upon adoption of a motion from the floor the election for that office (or offices) may be by voice.
c. Officers shall assume their official duties at the beginning of the new fiscal year and shall serve for a term of one (1) year or until their successors are elected and assume their duties.
d. A person shall not be eligible to serve more than two (2) consecutive terms in the same office.
The members of the nominating committee for officers of a local PTA/PTSA unit shall be elected.
a. There shall be a nominating committee consisting of three (3) members, two (2) of whom shall be elected by the executive board from its body, and one (1) elected by this association at a general membership meeting at least two (2) months prior to the election. There shall be one (1) alternate elected by the executive board and one (1) from the association. The committee shall choose its own chairman before the close of the general membership meeting at which they are elected.
b. The nominating committee shall select one (1) nominee for each office to be filled and report at least thirty (30) days prior to the election meeting.
c. During the election meeting, an opportunity shall be given for nominations from the floor.
d. Only those who have consented to serve if elected shall be eligible for nomination either by the committee or from the floor. No one may be eligible to election who has not been a member of this association or that of a feeder school for at least thirty (30) days.
e. To be eligible to vote in any election a person must have been a member for at least thirty (30) days.
a. In case a vacancy occurs in the office of president, the first vice president (vice president of communications) shall serve as president for the un-expired term. If there are co-presidents, then the remaining co-president will serve as president for the un-expired term. A vacancy occurring in any other office shall be filled for the un-expired term by a person elected by a majority vote of the remaining members of the executive board, notice of such election having been given.
b. In case a vacancy occurs in both the office of president and first vice president or both co-presidents and the first vice-president, the secretary shall call a special general membership meeting for the purpose of filling the vacant officer positions, prior notice having been given.
ARTICLE VII - DUTIES OF OFFICERS
The president and/or co-president shall:
a. preside at all meetings of this association, the executive board, and the executive committee;
#b. be a member ex-officio of all committees except the nominating committee and, if authorized to sign checks, the audit committee;
c. sign all legal documents, including contracts;
d. appoint members to special committees;
e. be responsible for other duties as may be assigned to him by the association, the executive board, or the executive committee;
f. delegate the work of the association to other officers or chairmen as may be appropriate;
g. coordinate the work of the officers and committees in order that the Purposes may be promoted; and
h. have completed the Illinois PTA President's Course before election or within six (6) months of election.
The vice president(s) shall act as aide(s) to the president and co-president.
The Vice President(s) and Vice President of Communications shall:
a. have completed the Illinois PTA Road to Success Course before election or within six (6) months of their election;
b. in conjunction with committee chairs, promote and market PTA sponsored events and activities on a school, district and community level
c. carry out any other duties decided upon by the executive board
d. and the Vice President of Communications shall act as the liaison between the executive board committee and the website/eblast communication to the school community.
The secretary shall
a. record the minutes of all meetings of this association, the executive board, and the executive committee;
b. have a current copy of the bylaws;
c. have a current membership list;
d. conduct correspondence of the association as directed; and
e. perform such other duties as may be delegated.
The treasurer shall:
a. receive all monies of this association and keep an accurate record of receipts and expenditures;
b. place all monies in a depository approved by the executive board;
c. pay out funds in accordance with the budget as approved by the membership and authorized by properly signed vouchers. Vouchers shall be signed by two (2) persons. Checks shall be signed by the treasurer and one (1) other duly elected and authorized officer.
d. present a written financial statement at every meeting of the association and at other times as requested by the executive board making a full report at the general membership meeting in September.
#e. be responsible for the remittance of the state and national portion of the dues paid by each member as directed in ARTICLE V of these bylaws;
f. provide the checkbook, all bank statements, canceled and voided checks, deposit slips, treasurer's record book and receipt book, vouchers and invoices for all disbursements to the audit committee;
g. be responsible for completion and filing of appropriate forms as may be required by Internal Revenue Service Regulations no later than the date established by the regulations;
h. not be a member of the audit committee; and
i. complete an official Illinois PTA Financial workshop.
All officers shall:
a. have completed the Illinois PTA Road to Success Course before election or within six (6) months of their election;
b. perform the duties prescribed in the parliamentary authority of this association in addition to those outlined in these bylaws and those assigned from time to time; and
c. deliver to their successors all official material prior to the start of the fiscal year with the exception of the treasurer who will deliver materials at the conclusion of the annual audit.
All officers shall:
e. have completed the Illinois PTA Road to Success Course before election or within six (6) months of their election;
f. perform the duties prescribed in the parliamentary authority of this association in addition to those outlined in these bylaws and those assigned from time to time; and
g. deliver to their successors all official material prior to the start of the fiscal year with the exception of the treasurer who will deliver materials at the conclusion of the annual audit.
ARTICLE VIII – GENERAL MEMBERSHIP MEETINGS
Regularly scheduled meetings of this association shall be held six (6) times during the school year. Dates of meetings shall be determined by the executive board and announced at the first general membership meeting of the year. Three (3) days notice shall be given of a change of date.
General membership meetings are convened to conduct the business of the association. Business shall include, but is not limited to: adoption of the audit report, adoption or amending the budget, amending the bylaws, the election of a nominating committee, and the election of officers.
Special meetings may be called by the executive board, two (2) days notice having been given.
The September meeting shall be the annual meeting at which time annual reports shall be given.
Bylaws of each local PTA/PTSA unit shall include a provision establishing a quorum.
A quorum for the transaction of the business of this association shall consist of eight (8) members which includes at least two (2) officers.
Proxy voting shall be prohibited.
ARTICLE IX - EXECUTIVE BOARD
This association shall establish an executive board.
The executive board shall consist of the officers of this association, the chairmen of standing committees, and the principal of the school or his representative.
(Suggestion: PTSAs should consider including student representatives.)
A PTA/PTSA member shall not serve as a voting member of a local PTA/PTSA unit's board while serving as a paid employee of or under contract to a local PTA/PTSA unit.
The executive board shall:
a. review tentative budget for recommendation as a proposed budget to the general membership for adoption;
b. transact necessary business in the intervals between general membership meetings and such other business as may be referred to it by this association;
c. create standing committees;
d. approve plans of work of the standing committees;
e. present reports and recommendations to the general membership meeting of this association;
f. approve routine bills within the limit of the budget; and
g. elect an audit committee.
Regular meetings of the executive board shall be held as decided by the current board and will be fixed accordingly by the board at its first meeting of the year. At least three (3) days notice shall be given if there is a change of the regular meeting date. Five (5) members including at least two (2) officers shall constitute a quorum.
Special meetings of the executive board may be called by the president or by a quorum of the board provided that members receive three (3) days notice.
Any appointed board member not performing duties as outlined in the bylaws or procedures may be removed by the affirmative vote of two-thirds (2/3) of the board members present and voting prior notice having been given. Any appointed board member absent for three (3) consecutive meetings without prior notice shall automatically forfeit his place on the board and be so notified.
The executive board shall upon the recommendation of the executive committee consider the removal of any officer not performing duties as outlined in the bylaws. An affirmative vote of two-thirds (2/3) of the board members present and voting shall be necessary for removal of an officer prior notice having been given.
ARTICLE X - EXECUTIVE COMMITTEE
The executive committee shall consist of elected officers.
Meetings shall be held at the call of the president or a majority of the executive committee. Two (2) days notice shall have been given. A majority shall constitute a quorum.
The committee shall meet as soon as the officers have been duly elected for the purpose of selecting the chairmen of standing committees and formulating tentative plans for their term of office.
The committee may transact business of this association in an emergency; however, no action shall be in conflict with that taken by the voting body of this association or the executive board.
ARTICLE XI - STANDING AND SPECIAL COMMITTEES
The executive board shall create such standing committees as it may deem necessary to promote the Purposes and carry on the work of this association. The chairman of standing committees shall be selected by the executive committee for a term of one (1) year.
The chairman of each standing committee shall present a written plan of work to the executive board for approval. No committee work shall be undertaken without the consent of the executive board.
Special committees may be created by the executive board or the membership as the need arises.
The local PTA/PTSA unit financial records must be audited annually at the close of the fiscal year and upon change of treasurer during the term of office.
An audit committee of at least three (3) members shall be elected by the executive board at its final meeting of the fiscal year. The committee shall examine the financial records and report its findings to the membership at the first general membership meeting of the new fiscal year. By decision of the executive board, an outside auditor may be used. Anyone authorized to sign checks is not eligible to audit the financial records.
The president shall be a member ex-officio of all committees except the nominating committee and, if authorized to sign checks, the audit committee.
ARTICLE XII - REPRESENTATION
This association may be represented at the region and district annual meeting and at the annual or special convention of the Illinois PTA as provided in the state bylaws.
(Suggestion: provide here for election of delegates)
This association shall be a member of the Glen Ellyn Council of Parent-Teacher Associations and shall pay dues and be represented as provided in the council bylaws. (This is only applicable if the PTA/PTSA unit is part of a council.)
ARTICLE XIII - RELATIONSHIP WITH NATIONAL PTA AND ILLINOIS PTA
This local PTA/PTSA unit shall be organized and chartered under the authority of the Illinois PTA in the area in which this local PTA/PTSA unit functions in conformity with rules and regulations not in conflict with the Bylaws of National PTA as the Illinois PTA may in its bylaws prescribe. The Illinois PTA shall issue to this local PTA/PTSA unit an appropriate charter evidencing the due organization and good standing of this local PTA/PTSA unit.
A local PTA/PTSA in good standing is one that:
a. adheres to the Purposes and basic policies of the PTA;
b. remits the national portion of the dues through the Illinois PTA to reach the national office by dates designated by National PTA;
c. has bylaws approved according to the procedures of the Illinois PTA; and
d. meets other criteria as may be prescribed by the Illinois PTA.
This local PTA/PTSA shall adopt bylaws for the governance of the association as may be approved by the Illinois PTA. Such bylaws shall not be in conflict with the Bylaws of National PTA or the Bylaws of the Illinois PTA.
Bylaws of this local PTA/PTSA unit shall include an article on amendments.
a. All local PTA/PTSA units' bylaws and amendments thereto shall be approved by the district director or the designated representative of the state board of directors. Bylaws shall be submitted for review upon request and/or every two (2) years.
b. If approved bylaws do not exist, the current ILLINOIS PTA BYLAWS FOR LOCAL PTA/PTSA UNITS shall be in effect.
This local PTA/PTSA unit shall collect dues from its members and shall remit a portion of such dues to the Illinois PTA as provided in the ARTICLE on Membership and Dues contained herein.
This local PTA/PTSA unit shall keep permanent books of account and records as shall be sufficient to establish the items of gross income, receipts, and disbursements of the association, including, specifically, the number of its members, the dues collected from its members and the amount of dues remitted to the Illinois PTA. Permanent books of account and records shall at all reasonable times be open to inspection by an authorized representative of the Illinois PTA.
The charter of this local PTA/PTSA unit shall be subject to withdrawal and the status of such association as a local PTA/PTSA unit shall be subject to termination in the manner and under the circumstances provided in the bylaws of the Illinois PTA.
DISSOLUTION: Voluntary End of Affiliation with PTA
A. To end affiliation with the State and National PTA, a local unit must legally dissolve in accordance with the process established in these Bylaws. Seeking legal counsel may be advisable.
1. Send a request for dissolution to the Illinois PTA office, containing the following:
a) a signed petition of fifteen (15) members or twenty-five percent (25%) of the membership not including members of the executive board of the local unit, whichever is larger, recommending dissolution;
b) current membership roster to determine eligibility to vote at a dissolution meeting;
c) notice of dissolution meeting, giving members thirty (30) day notification and seven (7) day reminder; method of distribution to membership.
2. Conduct a dissolution meeting of the general membership
a) an Illinois PTA representative shall be given opportunity to speak first;
b) determine that a quorum is present;
c) determine eligibility to vote;
d) place the question of dissolution before the members;
e) inform membership that to be adopted, the motion must receive a two-third (2/3) majority of those present and voting; and
f) conduct a ballot vote, and declare the results of such vote.
3. Minutes of the meeting must include:
a) membership roster used to verify eligibility to vote, and presence of quorum;
b) declaration of ballot results, including votes in the affirmative, negative or abstentions;
c) effective date of dissolution;
d) distribution of funds remaining following the payment of all outstanding legal obligations, in accordance with established IRS rules and regulations;
e) verification of tax status of any organization receiving funds; and
f) signature of certifying officers and date submitted.
B. Dissolution of the local unit ends all rights and privileges associated with affiliation with State and National PTA, and the local unit:
1. must cease and desist from any further use of a name that implies or connotes association with the National PTA and the Illinois PTA;
2. must cease and desist from using the Federal Employer Identification Number (FEIN) issued to the local unit as a constituent association organized by the authority of the Illinois PTA;
3. loses federal tax-exempt status as a constituent association of the National PTA and the Illinois PTA as authorized by the Internal Revenue Service;
4. must distribute all remaining funds to a recognized and approved 501 c 3 association, in accordance with IRS requirements, within thirty (30) days or those funds shall revert to the Illinois PTA;
5. notify all necessary governmental agencies of the action taken, including but not limited to: the Illinois Department of Revenue, the Illinois Secretary of State if incorporated, the Internal Revenue Service;
6. notify all entities with whom you do business of the action taken, including but not limited to:
banks, suppliers/vendors, insurance provider and school district;
7. perform a complete audit of the financial records of the local unit; and
8. provide the Illinois PTA via the state office, the following:
a) copy of the final audit;
b) copy of final report filed with the Internal Revenue Service;
c) copy of IRS Schedule N, distribution of remaining funds;
d) Copy of notification of dissolution to governmental agencies as required in B5 above.
C. The Illinois PTA, as the authority under whom the local unit was granted tax-exempt status, has the right as the holder of the group exemption to approve any organization receiving funds from the dissolved local unit.
#ARTICLE XIV - FISCAL YEAR
The fiscal year of this association shall begin on July 1mand end on the following June 30.
#ARTICLE XV - PARLIAMENTARY AUTHORITY
The rules contained in the current edition of Robert's Rules of Order Newly Revised shall govern the Forest Glen Elementary School PTA/PTSA in all cases in which they are applicable and in which they are not in conflict with these bylaws, the bylaws of National PTA, the bylaws of the Illinois PTA, or the articles of incorporation.
ARTICLE XVI - AMENDMENTS
a. These bylaws may be amended at any general membership meeting of this association by a two-thirds (2/3) vote of the members present and voting provided that notice of the proposed amendment shall have been given at the previous general membership meeting or written notice of the proposed amendment has been given to all members thirty (30) days in advance of the general membership meeting at which the amendment is to be considered, a quorum being present, and that the proposed amendments shall be subject to approval of the district director or the designated representative of the state board of directors of the Illinois PTA.
b. A committee may be appointed to submit a revised set of bylaws as a substitute for the existing bylaws by a majority vote at a meeting of this association or by a two-thirds (2/3) vote of the executive board. The requirements for adoption of a revised set of bylaws shall be the same as in the case of the amendment.
c. Two (2) copies of all proposed amendments or revisions shall be submitted to the district director or the designated representative of the state board of directors for review prior to presentation at a general membership meeting of the association for its consideration and action.
d. After approval by a two-thirds (2/3) vote at a general membership meeting of the association, two (2) copies of all amendments or revisions shall be sent for approval to the district director or designated representative of the state board of directors.
e. Submission of amendments or revised bylaws for approval by the Illinois PTA shall be in accordance with the Bylaws of the Illinois PTA.
This local PTA/PTSA unit shall include in its bylaws provisions corresponding to the Illinois PTA Bylaws as are identified herein by a double star (**).
The adoption of an amendment to any provision of the Illinois PTA Bylaws identified by a double star (**) shall serve automatically and without the requirement of further action by the Forest Glen Elementary School PTA to amend their corresponding bylaws. Notwithstanding the automatic character of the amending process, local PTA/PTSA units shall promptly incorporate such amendments in their respective bylaws.
Each local PTA/PTSA unit shall include in its bylaws provisions corresponding to the provisions of such of these bylaws as are identified by the number symbol (#).
The adoption of an amendment to any provision of the bylaws of the Illinois PTA identified by a number symbol (#) shall serve automatically and without the requirement of further action by Forest Glen Elementary School PTA to amend their corresponding bylaws.
Affirmation of Bylaws
(PLEASE CHECK and FILL OUT ONLY ONE)
__ These bylaws were voted upon and passed at the general membership meeting of the Forest Glen Elementary School PTA on __________________________________ (Date).
__ These bylaws were reviewed on ___________ (Date), and no changes were made. This was reported to the general membership on ______________ (Date).
Signed: ________________________________________ Date: _______________
Printed Name: ______________________________________________
Signed: ______________________________________________ Date: _______________
(PTA Secretary )
Printed Name: ______________________________________________
Approved by: _______________________________________ on ___________________________________
District/Region director or Date
designated representative of the state board of directors