Form 130 Membership Deletions - Ambucs

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Form 130
Membership Deletions
Date _______________
Chapter
no.
Chapter
Form completed by _______________________________________ Daytime phone _________________
J
J
J
J
Deletion(s) to be effective
1st quarter (June thru Aug)
2nd (Sept thru Nov)
3rd (Dec thru Feb)
4th (Mar thru May)
Note: To be effective, deletions must be reported to the
™ Resource Center before the closing date of the specified
AMBUCS
quarter (10th of the following month). Deletion reports received after a quarter’s closing date will become effective in the
next quarter. Closing dates: 1st quarter (Sept 10) • 2nd quarter (Dec 10) • 3rd quarter (Mar 10) • 4th quarter (June 10).
J
J
J
J
Member
no.
Prefix
Suffix
ID
Mr.
Mrs.
Ms.
Miss
(Jr., III)
First name
MI
Last name
J
J
J
J
Reason for deletion
resigned
deceased
suspended
transfered to chapter no.
J
moved to (new address)
City
State
Zip
–
Chapter offices currently held ____________________________________________________________________
J
J
J
J
Member
no.
Prefix
Suffix
ID
Mr.
Mrs.
Ms.
Miss
(Jr., III)
First name
MI
Last name
J
J
J
J
Reason for deletion
resigned
deceased
suspended
transfered to chapter no.
J
moved to (new address)
City
State
Zip
–
Chapter offices currently held ____________________________________________________________________
J
J
J
J
Member
no.
Prefix
Suffix
ID
Mr.
Mrs.
Ms.
Miss
(Jr., III)
First name
MI
Last name
J
J
J
J
Reason for deletion
resigned
deceased
suspended
transfered to chapter no.
J
moved to (new address)
City
State
Zip
–
Chapter offices currently held ____________________________________________________________________
Copies to—
Resource Center —Secretary, Newsletter Editor & Chapter President
AMBUCS
G
Distribution:
Need additional forms?
Go to or contact the
™ Resource Center
AMBUCS
Tel (336) 869-2166
Fax (336) 887-8451
G
G
TM
or write PO Box 5127 High Point, NC 27262

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