NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
National Forms
Revised 8-11-14
Special Thanks To
Achiever Rosie Anderson
Achiever Shirley H. Bell
Achiever Anne R. Harris
Achiever Rebecca T. Porter
Achiever Dorothy Roberts
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Table of Contents
By-Laws Amendment Form
Candidate
Election and Endorsement Check List
Official Nominating Form
Poll Watcher Form
Charter a Chapter
Formation of a New Chapter
Name of a New Chapter
Committee
Goals & Objectives
Report Form
Service Confirmation
Contact Information
Evaluation Form
Financial Form(s)
Achiever
Junior/Collegiate/Youth
Chapter Membership List
Chapter Quarterly Report
Form 990
Member-at-Large
Grievance Committee Worksheet
Hall of Fame Inductee Application
Leadership Grant Application and Disbursement Form
Membership
Achiever
Affiliate
Collegiate
Youth
Junior
Youth
Medical/Personal Data
Medical History
Parent Permission Form
Oath of Ethics
Contact Information
Credentials Report
Member-At-Large Form
Member-At-Large Referral
New Inductees Approval Form
Personal Data Sheet
Personal Information Update
Request for Transfer
Minutes Correction Form
Motion Form
Nomination Form
Notice of Demise
Officer Occupancy Preference Form
Pageant Entry Form
Recommendation Form
Scholarship Application
Scrapbook Competition Check List
Store (NWOA)
Vendor Booth Agreement Form
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
By-Laws Amendment Form
___________________
DATE
Region ____________________________________________________________________________________________
Chapter ________________________________________________________________________________________
Regional Director _______________________________________________________________________________
Amendment requested by: (National, Region, Chapter, Achiever, Committee, etc.)
______________________________________________________________________________________________________
NAME
______________________________________________________________________________________________________
ADDRESS CITY STATE ZIP CODE
___________________________________________________________________________________________
E-MAIL ADDRESS TELEPHONE
Article __________________________________________ Section ______________________________
Proposed By-Laws Amendment (please state wording exactly as you wish the Amendment to
appear).
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Rationale
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Signature __________________________________________________________________________________________
National, Region, Chapter, Achiever, Committee, etc.
________________ Accepted
________________ Denied
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Candidate for Election and Endorsement Check List
Candidate’s Name_______________________________________________________________
Candidate for the position of_______________________________________________________
Chapter_______________________________________________________________________
Chapter President_______________________________________________________________
Region Director____________________________________Region_______________________
==================================================================================
PLEASE CHECK ALL THAT APPLY
ENDORSEMENT LETTER/CHAPTER STATIONERY
SIGNED BY THE CHAPTER PRESIDENT
ENDORSEMENT LETTER/REGIONAL STATIONERY
SIGNED BY THE REGIONAL DIRECTOR
CANDIDATE IS FINANCIAL AND MEETS ALL CRITERIA
__________________________________________________________________________________
Signature of Chapter President Date
__________________________________________________________________________________
Signature of Regional Director Date
__________________________________________________________________________________
Signature of Candidate for Office Date
================================================================================
OFFICIAL USE BELOW THIS LINE
APPLICATION RECEIVED ON TIME
LATE APPLICATION
OFFICIAL NOMINATING PAPERS APPROVED
OFFICIAL NOMINATING PAPERS DENIED
___________________________________________________________________________________________
Signature of Nominating Chair Date
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
OFFICIAL NOMINATION FORM
Name ________________________________________________________________________
Address ______________________________________________________________________
City _________________________________ State________________ Zip Code ________
Phone______________________________________ e-mail
Region Chapter ________________________
Candidate for the Office of No
Number of years with present Chapter ______
Number of years of Active Service in NWOA
Have you had any experience or training in the specific office? Yes
If yes, please relate:
__________________
Why do you wish to serve in this office?
Do you qualify for this office according to NWOA Regional By-Laws? Yes No
Candidates may attach a one-page typewritten, double spaced resume (if desired to the
Nomination form when submitting it the Regional Nominating Committee Chairperson.
_______
Chapter President’s Signature Nominee’s signature
_______
Chapter Financial Secretary’s Signature Date
Mail To: Regional Nominating Committee
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Official Poll Watcher Form for Elections
NAME OF CANDIDATE_________________________________________________________
CHAPTER_____________________________________________________________________
REGION______________________________________________________________________
NOMINATED FOR THE OFFICE OF______________________________________________
NAME OF POLL WATCHER_____________________________________________________
(PRINTED NAME)
SIGNATURE OF POLL WATCHER_______________________________________________
(SIGNATURE)
=====================================================================
OFFICIAL USE ONLY BELOW THIS LINE
NOMINATING CHAIR__________________________________________________________
ELECTIONS CHAIR____________________________________________________________
ELECTION DATE______________________________________________________________
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Application for the Formation of a New Chapter
Date_______________________________
I (We), _______________________________________________________________________
do hereby petition National/Regional to establish a new Chapter in the:
______________________________________________________________Region
_______________________________ ________________________________
City State
________________________________________ _____________________________________
Printed Name of Organizer Signature of Organizer
________________________________________ ____________________________________
Printed Name of Organizer Signature of Organizer
_______________________________________ ____ ___________________________________
Printed Name of Organizer Signature of Organizer
Recommendation of the National President or Chapter Establishment Committee Chairperson:
______________________________________________________________________________
______________________________________________________________________________
Recommendation of the Regional Director:
______________________________________________________________________________
______________________________________________________________________________
________________________________________ _______________________________________
Signature of the National President Date
________________________________________ _______________________________________
Signature of the Regional Director Date
Please send one copy to the National President, Regional Director, and National Membership Chairperson.
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Application for the Name of a New Chapter
Date_______________________________
I (We), _______________________________________________________________________
do hereby petition National/Regional to accept the name listed below for a new Chapter in the:
_______________________________________________________________________Region
____________________________________ _____________________________________
City State
We submit the name of:
________________________________________________________________________________
________________________________________________________________________________
Signature of Regional Director
________________________________________ _________________________________________
Printed Name of Organizer Signature of Organizer
________________________________________ _________________________________________
Printed Name of Organizer Signature of Organizer
_______________________________________ ____ ___________________________________
Printed Name of Organizer Signature of Organizer
Recommendation of the National President, and National Executive Board
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Signature of the National President Date
National Executive Board Action: ________Approved ________Denied
Please send one copy to the National President, Regional Director, and National Membership Chairperson.
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Committee Goals & Objectives
______________________
DATE
Committee____________________________________________________________________________
Chairperson___________________________________________________________________________
Co-Chairperson________________________________________________________________________
Committee Members ___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What were the Goals of this Committee?____________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What are the Objectives of this Committee? _________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
List Measurable Outcomes of Committee Work ______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Dr. Maudest Walls Stewart, Founder (1906 =- 1995)
National Committee Report Form
Committee Name
Committee Chairperson
Co-Chairperson(s)
Committee Members (Achievers)
The Committee met on We discussed the following items:
Submitted by Date
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Community Service Confirmation Form
Chapter Name_____________________________________Region_____________________________
Division Member______________________________________________________________________
Division______________________________________________________________________________
Service Supervisor/Witness_____________________________________________________________
I __________________________________________________________________supervised/witnessed
______________________________________________________________while he/she performed the
following community service tasks:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Total Community Service Time_________________Hours and _____________Minutes if applicable.
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature of Division Member Date
_____________________________________________________________________________________
Signature of Supervisor/Witness Date
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
National Committee
Contact Information
___________________________________________________
Name
___________________________________________________
NWOA Region
___________________________________________________
NWOA Chapter
___________________________________________________
Mailing Address (Number and Street)
___________________________________________________
Mailing Address (City, State, and Zip Code
___________________________________________________
Home Phone
___________________________________________________
E-Mail Address
___________________________________________________
Fax Phone
___________________________________________________
Office Phone (Optional)
___________________________________________________
Cellular Phone (Optional)
Revised 8-11-14
National Women of Achievement, Incorporated
EVALUATION FORM
Rating Scale
5 43 2 1
Excellent Fair Poor
Very Good Good
HOTEL
Check-In
Staff
Guest Room
Food
EVENT
Registration
Hospitality
Materials
Time Lines
Reports
Activities
WORKSHOPS
Topics
Presentations
Time Lines
Achiever
Response
COMMENTS _________________________________________________________
_____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Revised 9-11-14
National Women of Achievement, Inc. Date ___________
Chapter Financial Form Page ____ of ____
Adult Chapter Only
The information on this form should be completed by each Chapter Financial Secretary and forwarded to the National Financial
Secretary on or before February 01 of each year. (Please Type or Print)
Chapter City State Zip
Chapter President E-mail address
Address
Telephone
Region
Regional Director
National Chapter Assessment
National Chapter Assessment ($75.00)
National Scholarship Assessment ($150.00)
National Affiliate Fee ($50.00)
National Reinstatement Fee ($50.00)
National New Chapter Charter Fee ($50.00)
National Life Membership Fee ($1000.00)
National Per Capita @ $60 x ( ) # Regular Members
Late Fee @ $10.00 per member (After February 15)
Number of National Life Members ( )
TOTAL AMOUNT SENT
Please Make Checks payable to NATIONAL WOMEN OF ACHIEVEMENT or NWOA and mail to
National Women of Achievement, Inc.
National Financial Secretary
P.O. Box 14909
Houston, Texas 77221
_______________________________ ___________________________________
Signature of Chapter President Signature of Chapter Financial Secretary
_______________________________ ___________________________________
Signature of National Treasurer Signature of National Financial Secretary
(Send four copies of this completed form to the Financial Secretary)
National Women of Achievement, Inc.
Chapter Financial Form
JUNIOR, YOUTH & COLLEGIATE
The information on this form should be completed by each Chapter Financial Secretary and forwarded to the National Financial
Secretary on or before February 01 of each year. (Please Type or Print)
Chapter City State Zip
Chapter President Email address
Address
Telephone
Region
Regional Director
National Chapter Assessment ($20.00) JUNIORS YOUTH/COLLEGIATE
National Reinstatement Fee ($20.00) $ $
National New Chapter Charter Fee ($20.00) $ $
Late Fee per member (After February 15) ($5.00) $ $
National Per Capita @ $20 x ( ) # Junior Members $ $
National Per Capita @ $20 x ( ) Youth Members $ $
National Per Capita @ $20 x ( ) Collegiate Members $ $
Total Assessments $ $
$ $
TOTAL AMOUNT SENT $$
Please Make Checks payable to NATIONAL WOMEN OF ACHIEVEMENT or NWOA and mail to
National Women of Achievement, Inc.
National Financial Secretary
P. O. BOX 14909
Houston, Texas 77221
_____________________________________ ___________________________________
Signature of Chapter President Signature of Chapter Financial Secretary
____________________________________ ___________________________________
Signature of National Treasurer Signature of National Financial Secretary
(Send four copies of this completed form to the Financial Secretary)
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
National Quarterly Financial Report
For
Period __________________ Fiscal Year ___________
Chapter ________________________________________
Chapter President _______________________________
Region ________________________________________
Treasurer __________________________________________ Telephone _______________________
E-mail Address _______________________________________________________________________
REVENUE $ ____________
1. Membership Dues/Assessments-NWOA $ ____________
Membership Dues/Assessments-NWOA Youth $ ____________
Membership Dues/Assessments-NYA $ ____________
Membership Dues/Assessments-NJA $ ____________
2. Contributions, Gifts, or Grants $ ____________
3. Registration-NWOA $ ____________
Registration-NWOA Youth Support $ ____________
Registration-NYA $ ____________
Registration-NJA $ ____________
4. Government Contributions $ ____________
5. Fund Raiser(s) Profile for Scholarships/NWOA Queen $ ____________
6. Other (Fiesta Party, Raffle, T-Shirts)
EXPENSES $ ____________
1. National Per Capita and Assessments-NWOA $ ____________
National Scholarship Assessment – NWOA $ ____________
2. Regional Per Captia and Assessment-NWOA $_____________
Regional Queen Scholarship Assessment $ ____________
Regional Queen Scholarship Fund raiser $ ____________
Regional Per Captia and Assessments-NYA Assessment $ ____________
Regional Per Captia and Assessments-NJA Assessment $ ____________
Regional Per Captia and Assessments-Collegiate Assessment $ ____________
3. Administrative Supplies $ ____________
4. Profile Facility Rental $ ____________
5. Fundraising Expenses (Printing, Awards, Gifts) $ ____________
6. Conferences, Conventions and Meetings $ ____________
7. Other (Bank Fees, Bereavement, T-Shirts $ ____________
TOTAL EXPENSES
NET BALANCE: (REVENUE LESS EXPENSES) $ ____________
ADD: Beginning Bank Balance January 1 $ ____________
$ ____________
Other Assets (Youth Account) $ ____________
Other Assets (Scholarship Account)
FUND BALANCE AS OF ______________
Prepared By: ________________________________________
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Region/Chapter 990 Financial Report Form
Chapter __________________________________________________________________________
Chapter President __________________________________________________________________
Region ___________________________________________________________________________
Regional Director __________________________________________________________________
Financial Secretary ________________________________Phone ( ) ___________________
Email Address ____________________________________________________________________
Date __________________________
REVENUE
1. Membership Dues and Assessments $ ____________________
2. Contributions, Gifts, or Grants $ ____________________
3. Direct or Indirect Public Support $ ____________________
4. Government Contributions $ ____________________
5. Fund Raiser(s) $ ____________________
6. Other (Specify) $ ____________________
TOTAL REVENUE $ ____________________
EXPENSES $ ____________________
1. National and Regional Dues and Assessments $ ____________________
2. Scholarship Disbursements $ ____________________
3. Affiliate Fees $ ____________________
4. Administrative Expenses $ ____________________
5. Fund Raising Expenses $ ____________________
6. Conference, Conventions, and Meetings $ ____________________
7. Other (Specify) $ ____________________
TOTAL EXPENSES
NET BALANCE (REVENUE LESS EXPENSES $ ____________________
Prepared By ____________________________________________________________________
Email Address __________________________________________________________________
Phone ( ) ______________________________________________
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Member-at-Large Financial Form
Date __________________
Name ______________________________________________________________________________
First Middle Last
Home Address ____ City State Zip Code
Street
Telephone No._____________________________ Cell Number ___________________________
E-Mail Address ____________________________________________________________________
NWOA Chapter nearest you:___________________________________________________________
Have you attended any of their meetings? ________ Yes ________ No ______
If Yes, how many? __________________
National Fees: $ _____________
Make your Money Order/Cashier’s Check to National Women of Achievement, Inc.
Please send to
National Women of Achievement, Inc.
Financial Secretary
P. O. Box 14909
Houston, Texas 77221
Your Signature __________________________________________________________
Please do not write below this line:
************************************************************************************
Date Received ___________________________________________
_____________________________________________________________________________________
National Financial Secretary Signature Date
_____________________________________________________________________________________
National Treasurer Signature Date
_____________________________________________________________________________________
National President Signature Date
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Grievance Committee Worksheet
Statement of Grievance ______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Received From _______________________________________________________________________
Chapter_________________________________________Region_______________________________
Date Received ________________________________________________________________________
Proposed Remedy _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Action Taken _________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Supporting Evidence attached___________________________________________________________
Grievance Committee Recommendation__________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Hall of Fame Inductee Application
Name ________________________________________________Date____________________
Home Address __________________________________________________________________
City/State ZIP Code
Telephone Number:_______________E-mail Address__________________________________
Please list three (3) significant contributions you have made to NWOA that enhances the organization.
_____________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________________________
Please list five (5) other services rendered to the community, or with state or national organizations.
______________________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
List at least three (s) Regional Conferences attended in the last five years. _________
Years you attended _________ _________ _________ _________
List at least two (2) CON-WOA Sessions attended in the last five years. _________
Years you attended _________ _________ _________ _________
Recommended and approved by:_____________________________________________Chapter
Signature of Chapter President_______________________________Date __________________
Signature of Chapter Financial Secretary_______________________Date __________________
Please mail or e-mail this Application by the deadline along with a clear picture and your personal biography,
not to exceed 500 words by the deadline to the National Hall of Fame Chairperson. (Please type/print or key-
stroke - double spaced)
Mail to the Hall of Fame Induction Chairperson
Do not write below this line
=====================================================================
Confirmation of National Financial Secretary by: ___________________________________
Signature of the Hall of Fame Chairperson _________________________________________
Approved_________ Denied___________
Comments____________________________________________________________________________________
_________________
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Leadership Grant Application and Disbursement Form
Last Name First Name MI
Address Apt. City State Zip Code
DOB (MM/DD/YYYY E-mail Address
Advisor Name Division
Leadership Training Event Date(s) of Event
In Brief, why do you want to participate I this event, and how will it benefit you?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Applicant Signature___________________________________________Date ____________________
For Official Use Only
_______________________________________________________________________________________________________________
Date: Received ____/____/____ Date Processed ____/____/____
Action Taken: Approved ( ) Denied ( ) Reason: _______________________________________
Disbursement Information
Itemization $ _______________Travel $ __________ Accommodations ______ Other ________
Total Disbursement$ $_______ Recipient Initial Verifying Receipt of Funds: _________Date _____
______________________________________________________________________________ _________________
Chapter President Signature Date
_____________________________________________________________________________ __________________
Financial Secretary Signature Date
_____________________________________________________________________________ __________________
Treasurer Signature Date
ANY APPROVED DISBURSEMENT OF FUNDS FOR LEADERSHIP GRANTS CANNOT BE REPORTED AS SCHOLARSHIP
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Achiever Membership Application
Chapter
Name Birthdate _______
Month Day
Home Address _______
Street City State Zip
Telephone No._____________________________ E-mail _________________________________
Spouse Name Spouse Occupation ______
Number of Children Age Range
Educational Experience: _______
_______
Occupational Experience _______
Present Position: _______
_______
_______
_______
Current Organization Memberships: _______
Hobbies: _______
_______
_______
_______
Church Affiliation: _______
_______
References:
1. _______
2. _______
3. _______
National Women of Achievement, Incorporated
Affiliate Membership
Please indicate Membership Status Affiliate by Circling either (R) for Regular Membership
or (L) for Life membership.
Please Print Legibly
NAME (Last, First) please print NAACP NCNW UNCF
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
RL RL RL
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVENMENT, INC
NATIONAL COLLEGIATE ACHIEVERS
Membership Application
CHAPTER
Personal Information-Please Type or Print
Name: _________________________________________ Date: __________________
Last First Middle
Address:
Street City State Zip Code
Telephone #:(___)_________________________ Date of Birth: _______________
Parents
Father’s Name: ______________________________Occupation: _______________
Telephone: ______________________Address if different from yours:______________
Mother’s Name: _____________________________ Occupation: ________________
Telephone: ______________________Address if different from yours: ______________
EDUCATIONAL INFORMATION:
High School: ________________________________
College ____________________________________
Academic Interest: ______________________________________________________
Clubs/Hobbies: _________________________________________________________
______________________________________________________________________
Religious Affiliation:
Church: ________________________________ Pastor ______________________________
Participation: ___________________________________________________________
______________________________________________________________________
Recommended by: _______________________________Telephone #______________
Date: Inducted: __________________________ Membership fees Paid: ____________
____________________________________ ____________________________
Applicant’s Signature Parent’s Signature
____________________________________ ____________________________
Regional Collegiate Director s Signature Chapter Advisor’s Signature
____________________________________ ____________________________
National Collegiate Director’s Signature National President’s Signature
White Copy – Chapter Yellow Copy – National Youth Director Pink Copy- National President Gold Regional Youth Director
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVENMENT, INC
NATIONAL YOUTH ACHIEVERS
Membership Application
CHAPTER
Personal Information-Please Type or Print
Name: _________________________________________ Date: __________________
Last First Middle
Address:
Street City State Zip Code
Telephone #:(___)_________________________ Date of Birth: _______________
Parents
Father’s Name: ______________________________Occupation: _______________
Telephone: ______________________Address if different from yours:______________
Mother’s Name: _____________________________ Occupation: ________________
Telephone: ______________________Address if different from yours: ______________
EDUCATIONAL INFORMATION:
School: ________________________________Grade: _______Teacher ___________
Telephone #: _________________________Address:___________________________
Seniors Only: -- Preferred College: _______________________________________
Academic Interest: ______________________________________________________
Clubs/Hobbies: _________________________________________________________
______________________________________________________________________
Religious Affiliation:
Church: ________________________________ Pastor ______________________________
Participation: ___________________________________________________________
______________________________________________________________________
Recommended by: _______________________________Telephone #______________
Date: Inducted: __________________________ Membership fees Paid: ____________
____________________________________ ____________________________
Applicant’s Signature Parent’s Signature
____________________________________ ____________________________
Regional Youth Director s Signature Chapter Advisor’s Signature
____________________________________ ____________________________
National Youth Director’s Signature National President’s Signature
White Copy – Chapter Yellow Copy – National Youth Director Pink Copy- National President Gold Regional Youth Director
NATIONAL WOMEN OF ACHIEVENMENT, INC
NATIONAL JUNIOR ACHIEVERS
Membership Application
CHAPTER
Personal Information-Please Type or Print
Name: _________________________________________ Date: __________________
Last First Middle
Address:
Street City State Zip Code
Telephone #:(___)_________________________ Date of Birth: _______________
Parents
Father’s Name: ______________________________Occupation: _______________
Telephone: ______________________Address if different from yours:______________
Mother’s Name: _____________________________ Occupation: ________________
Telephone: ______________________Address if different from yours: ______________
EDUCATIONAL INFORMATION:
School: ________________________________Grade: _______Teacher ___________
Telephone #: _________________________Address:___________________________
Academic Interest: ______________________________________________________
Clubs/Hobbies: _________________________________________________________
______________________________________________________________________
Religious Affiliation:
Church: ________________________________ Pastor ______________________________
Participation: ___________________________________________________________
______________________________________________________________________
Recommended by: _______________________________Telephone #______________
Date: Inducted: __________________________ Membership fees Paid: ____________
____________________________________ ____________________________
Applicant’s Signature Parent’s Signature
____________________________________ ____________________________
Regional Junior Director s Signature Chapter Advisor’s Signature
____________________________________ ____________________________
National Junior Director’s Signature National President’s Signature
White Copy – Chapter Yellow Copy – National Youth Director Pink Copy- National President Gold Regional Youth Director
Revised 8-11-14
National Women of Achievement, Inc.
NATIONAL YOUTH ACHIEVERS
PERSONAL DATA SHEET
Student's Name
Parent's Name
Area Code & Phone Number
In the event of an emergency, please list the following information:
Name of Contact Person Area Code and Phone Number
Does your son/daughter have any serious medical problems that Advisors should be aware of?
Yes No (If yes, please explain and list medications)
In the event of minor illnesses such as headaches, upset stomach, etc., do you grant permission for over
the counter medications such as Tylenol, Advil, Pepto Bismol to be given to your son/daughter?
Yes No
Youth Achiever/Junior Achiever's Signature Parent's Signature
Notary's Signature Expiration Date
PHYSICIAN'S STATEMENT
I, , verify that this student, ____________
Physician's Name
Student's Name
is in good health, and may participate in the (National Conference/Regional Conference) trip.
PHYSICIAN'S SIGNATURE ______________________________
ADDRESS (PLEASE INCLUDE CITY & STATE
AREA CODE & TELEPHONE NUMBER __________________________________________
National Women of Achievement, Inc.
NATIONAL YOUTH ACHIEVERS
MEDICAL HISTORY
Youth Achievers Name
ALLERGIES
PAST ILLNESSES
Is the child healthy and able to participate in skating, bowling, or other team sports?
Is the child now on any type of medication?
If so, what kind and how often should dosage be taken?
Kind Frequency
Kind Frequency
Kind Frequency
Does the child require aids? (i.e. eyeglasses, hearing aid,...)
Has the child been treated for?
Bleeding Convulsions
Heart Trouble Hypertension
Lung Disease Kidney Problems
Diabetes Epilepsy
Other (State)
My permission is given to any qualified Physician or emergency room Physician to treat my child.
The above information is true and accurate.
Signature
Parent(s) or Guardian
Date Chapter Name
National Women of Achievement, Inc.
NATIONAL YOUTH ACHIEVERS
PARENT PERMISSION FORM
Chapter
City
Date
This is to certify that my child,
Name of Youth Achiever
has my permission to attend the National Youth Achiever National Conference/Regional Conference in
. It is my understanding that this trip, which
City, State
is being taken under the auspices of NWOA, Inc. will be supervised by competent ladies who will be
traveling with the group. However, I hereby release NWOA, Inc. from liability and waive any and all
claims against the organization individually and collectively for injuries which might be received during
the trip, either at the destination or in traveling to or from said destination.
Signature - Parent or Guardian
Signature - Youth Achiever Advisor
Signature - Youth Achiever Chapter President
Notary Signature and Seal
OATH OF ETHICS
FOR
NATIONAL YOUTH ACHIEVERS
All NYA members in attendance must be present at all meetings and be on time.
Entertainment has been planned by the Host Chapter. Show your gratitude by attending the activities and be
punctual.
Respect the property of the hotel meeting site. Youth must abide by the regulations of the establishment. No
running in the halls, congregating in unassigned areas, and no joy riding in the elevators.
Youth Achievers should be in their rooms by 1:00 a.m.; no visitation after this hour (MANDATORY), with option
of extending curfew time, if circumstances warrant it, at the discretion of host chapter and National Youth
Achiever Director/Regional Youth Coordinator.
No post-curfew parties, no coed visitation; no extension of the party is permissible.
Proper and adequate adult chaperones must be provided at all social affairs.
Avoid unnecessary boisterousness (Loud, noisy, and undisciplined).
Cell phones must be turned off. No TEXT MESSAGING is allowed during conference programs. For any Youth
caught talking or text messaging during any conference program, the phone will be collected and kept by the
Advisors. Phones will be returned at discretion of the advisors.
Youth Achievers are expected to conduct themselves at all times in a manner that will be a credit to the
organization, good manners and proper attire (Read Dress Code)
An Oath of Ethics Board will be appointed by NYA Director/ Regional Youth Coordinator for disciplinary actions
for those youth breaking the Oath of Ethics. The decision of the Board is final. Possible action: no voting
participation, no youth competition, accessed a fine or sent home.
Each chapter is responsible for making Youth Achievers aware of this Oath of Ethics before attending National
Convention or Regional Conference.
Each chapter will duplicate enough copies of the oath, and have each Youth Achiever planning to attend the
convention sign along with parent signatures and Chapter Advisor. The advisor will please bring codes to the
convention.
Youth Achiever Signature Parent/Guardian Signature
I have reviewed this Oath of Ethics with the above signed Youth Achiever.
Chapter Advisor Signature
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Credentials Report Form
Year ________________
Chapter ____________________________________________________________________________
Chapter President __________________________________________________________________
Region _____________________________________________________________________________
Number of Financial Members _________________
National Officers Registered ____________
Regional Officers Registered ____________
Life Members Registered ____________
Collegiate Advisors Registered ____________
Youth Advisors Registered ____________
Junior Advisors Registered ____________
Total Voting Strength __________
Chapter President ________________________________________________________________
Signature Date
Chapter Financial Secretary ______________________________________________________
Signature Date
National Financial Secretary ______________________________________________________
Signature Date
LIST AND PRINT NAMES OF ALL CHAPTER MEMBERS IN ATTENDANCE (TWO COLUMNS)
_______________________________________ __________________________________________
_______________________________________ ___________________________________________
_______________________________________ ___________________________________________
______________________________________ ____________________________________________
______________________________________ ____________________________________________
______________________________________ ____________________________________________
______________________________________ ____________________________________________
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
MEMBER-AT-LARGE APPLICATION
Chapter nearest you (If applicable) Date ____________
Name Birthdate
Month Day
Home Address ____ City State Zip Code
Street
Telephone No._____________________________ Cell Number ___________________________
E-Mail Address ____________________________________________________________________
Spouse Name _____ Spouse Occupation
Number of Children Age Range
Educational Experience:
______
______
Occupational Experience
______
______
Present Position: ______
_____________
Current Organization Memberships: ______
______
Hobbies:
______
Church Affiliation: ______
References: ______
1. ______
2.
______
_______
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Member-at-Large Referral Form
I would like to recommend the following person(s) as members-at-large
1. Name
Address
City State Zip Code
Telephone Best time to call
2. Name
Address
City State Zip Code
Telephone Best time to call
3. Name
Address
City State Zip Code
Telephone Best time to call
Your Name
Address ________________________________________City ______________State______Zip______
Telephone Cell Phone
Email
__________________________________________________________________
Achiever’s Signature
National Women of Achievement, Incorporated
NEW INDUCTEES
APPROVAL FORM
Chapter: _______________________________________________________
Address________________________________________________________
City State Zip code
Region ___________________________________________
Please List Names Of Persons To Be Considered For Induction
NAME APPROVED DISAPPROVED
____________________________________________ ______________ ______________
____________________________________________ ______________ ______________
____________________________________________ ______________ ______________
____________________________________________ ______________ ______________
____________________________________________ ______________ ______________
____________________________________________ ______________ ______________
____________________________________________ ______________ ______________
____________________________________________ ______________ ______________
____________________________________________ ______________ ______________
PLACE OF INDUCTION: ____________________________ INDUCTION DATE _____________
CHAPTER PRESIDENT ___________________________________ Telephone# _______________
REGIONAL DIRECTOR ___________________________________ Telephone# ______________
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
PERSONAL DATA SHEET
Chapter__________________________ Date ____________
Name Birthdate
Month Day
Home Address ____ City State Zip Code
Street
Telephone No._____________________________ Cell Number ___________________________
E-Mail Address ____________________________________________________________________
Spouse Name _____ Spouse Occupation
Number of Children Age Range
Educational Experience:
______
______
Occupational Experience
______
______
Present Position: ______
_____________
Current Organization Memberships: ______
______
Hobbies:
______
Church Affiliation: ______
References: ______
1. ______
2.
______
_______
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Personal Information Update
PLEASE PRINT OR KEYSTROKE
Achiever______________________________________________________________________
Address_______________________________________________________________________
CITY STATE ZIP CODE
Telephone__________________________________Cell Number_________________________
E-mail Address_________________________________________________________________
Birthday___________________________________Anniversary__________________________
The above information is for the use of NWOA Division Members only.
PLEASE SUBMIT UPDATED INFORMATION TO THE:
NATIONAL CORRESPONDING SECRETARY
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Request for Transfer
I, ____________________________________________________________________________
DIVISION MEMBER’S NAME (PRINT OR KEYSTROKE)
Do hereby request a transfer from __________________________________________________
NAME OF CHAPTER
To ___________________________________________________________________________
NAME OF CHAPTER
REASON FOR TRANSFER – PLEASE CHECK ONE
Change of Residence – from one City to another
Change of Residence – from one State to another
Change of Residence – within the same City
Other Reason – Please Comment
Comment(s)___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________
Signature of Chapter President_____________________________________________________
Signature of Regional Director_____________________________________________________
Signature of National President____________________________________________________
National Membership Chairperson (copy)
Action taken: ________Approved ________Denied
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Minutes Correction Form
Meeting: __________________________________________________ Date ________________
Minutes Recorded by _____________________________________________________________
Correction Made by _______________________________________________________________
Chapter ___________________________________________________________________________
Region ____________________________________________________________________________
Correction (Page and Paragraph)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Correction (Page and Paragraph)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Correction (Page and Paragraph)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Correction (Page and Paragraph)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
MOTION FORM
Date: Meeting
I move that,
Motion made by Achiever/Chapter:
Seconded by Achiever/Chapter:
Action Taken:
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
NOTICE OF DEMISE
Name of Deceased
_____________________________________________________________________________________
First Middle Last
Division _____________________________________________________________________________
Chapter _____________________________________________________________________________
Chapter President ____________________________________________________________________
Region ______________________________________________________________________________
Region Director ______________________________________________________________________
Date of Death ________________________________________________________________________
Date of Burial ________________________________________________________________________
Please check the appropriate category (s):
______ Program Available
______ No Program Available
______ Picture Available
______ No Picture Available
_____________________________________________________________________________________
Signature of Chapter President Date
_____________________________________________________________________________________
Signature of National Chaplain Date
_____________________________________________________________________________________
Signature of National Historian Date
Please mail one copy to the National Chaplain and one copy to the National Historian
Revised 8-11-14
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Officer Hotel Occupancy Preference Form
_________________________
DATE
______________________________________________________________________________
Name of Officer
______________________________________________________________________________
Officer’s Address City State ZIP Code
______________________________________________________________________________
Telephone Number Cell Number
I WISH TO SHARE A ROOM WITH THE FOLLOWING PERSON:
______________________________________________________________________________
Name
______________________________________________________________________________
Address City State ZIP Code
______________________________________________________________________________
Telephone Number Cell Number
Date of Arrival____________________________Date of Departure_______________________
Special Request(s)_______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PLEASE EXCUSE ME, I CANNOT ATTEND
Comments_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Name PAGEANT ENTRY FORM Zip
Address
Telephone Chapter ____________
Biography: City
E-mail
Amount Enclosed
Date Received
♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦
Achiever , Regional Director
Achiever _________________________________, Chapter President
Achiever , Chairperson
Achiever , Consultant
Achiever , Co-Chairperson
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
Recommendation Form for National Consideration
Date
Region making the recommendation
Regional Director Telephone
Mailing Address City
State Zip Code E-mail
Please Note: One recommendation per form.
This form may be photo copied.
Please type or print.
This form may be scanned into your computer.
Recommendation:
Rationale: Date
Date
Signatures Date
Regional Director
Chairperson Date
Compiled by
Position
Action taken by National
Revised 8-11-14
National Women of Achievement, Inc.
SCHOLARSHIP APPLICATION
FILL IN COMPLE
Chapter______________________
Application for Scholarship: School Preference:
Name: ___________________________________________________________________________
Last Name First Name M.I.
Address _______________________________________________________ ________________
Street Address City County State Zip Telephone
Date of Birth ___________________ Age_________ Sex __________ Birth Place ______________
Parent/Guardian ___________________________________________________________________
Name Address Relationship
High School Attended _____________________________ Class Rank________ of _____ graduates
S.A.T./A.C.T. scores ___________________________ High School Grade Point Average ________
Are you a graduate of an accredited High School with 16 units of works? Yes ( ) No ( ) Extra
Curricular Activities ________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Honors/Awards ____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
List any school and/or community involvements. What offices did you hold if any? ______________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
NWOA Chapter ___________________________________________________________________
List any part-time employment you may have had ________________________________________
_________________________________________________________________________________
List all hobbies and talents you have ___________________________________________________
__________________________________________________________________________________
List all organizations that you have been an active member of and list the years.__________________
__________________________________________________________________________________
__________________________________________________________________________________
Additional Information Required:
Submit two letters of recommendation;
One from your Pastor, religious or community leader. *Cannot be from relatives.
A recommendation letter from your High School Counselor or an instructor.
An official High School Transcript sealed.
An acceptance letter from a college, university or post secondary institution.
Write an essay explaining why you want to go to college and how this scholarship could assist you in
preparing for your future educational career. (500 words or less)
__________________________________________
APPLICANT SIGNATURE
___________________________________________________________________________________
DO NOT WRITE BELOW THIS LINE
All Requirements Included? ( ) YES ( ) NO
Action Taken: Accepted ( ) Denied ( ) Canceled ( )
Comments __________________________________________________________________________
___________________________________________________________________________________
Date Received: _________________________ Date Processed:______________________________
Achiever Beatrice Mayes, National President
PLEASE RETURN APPLICATION TO
Scholarship Chairperson
Achiever Catherine Burnley
P. O. Box 14909
Houston, TX 77221
NWOA
NATIONAL WOMEN OF ACHIEVEMENT, INCORPORATED
National Scrapbook Competition Check List
________________________
DATE
Chapter _______________________________________________________________________
Name_________________________________________________________________________
Address_______________________________________________________________________
CITY STATE ZIP CODE
(_______)_________________(________)__________________________________________________________
TELEPHONE NUMBER CELL NUMBER E-MAIL ADDRESS
Chapter President_______________________________Region__________________________
PLEASE CHECK ONE:
CHAPTER SCRAPBOOK (CHAPTER OF THE YEAR)
CHAPTER PRESIDENT’S SCRAPBOOK
(CHAPTER PRESIDENT OF THE YEAR)
ACHIEVER SCRAPBOOK (ACHIEVER OF THE YEAR)
REGIONAL DIRECTOR SCRAPBOOK
(REGIONAL DIRECTOR OF THE YEAR)
COLLEGIATE DIVISION SCRAPBOOK
YOUTH DIVISION SCRAPBOOK
JUNIOR DIVISION SCRAPBOOK
FOR JUDGE(S) USE ONLY BELOW THIS LINE
TOTAL SCORE________________
COMMENTS_______________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Signature of Judge__________________________________________________________________
National Women of Achievement, Incorporated
NWOA Store
5422 Madden Lane
Houston, Texas 77048
Phone: 713-734-4381
E-mail: [email protected]
Order Form
FROM: SHIP TO:
Name _________________________________________ Attention _______________________________
Chapter _______________________________________ Address ________________________________
Date __________________________________________ City/State/Zip ___________________________
Phone ________________________________________ E-mail _________________________________
ITEM DESCRIPTION QUANITY UNIT COST TOTAL
T-shirt (Gold) Large $12.00
$12.00
1X $13.00
2X $14.00
3X $12.00
T-Shirt White) Large $12.00
1X $13.00
2X $ 8.00
White Towel (Medium) $ 6.50
White Hand Towel (Small) $ 6.50
Gold Hand Towel (Gold) $12.00
Visor Baseball Cap $15.00
Regular baseball Cap $ 3.00
Canvas Bag $30.00
Papyrus Picture $15.00
NWOA Pin (Small) $30.00
NWOA Pin (Large) $30.00
NWOA Rhinestone Pin
Merchandise Total
Shipping Total
Total Cost
Shipping Cost Check or Money Order
If order totals: Add
Up to $19.00 $ 7.00
$19.01-$39.00 $ 9.00
$39.01-$59.00 $11.00
$$59.01-$79.00 $13.00
$79.01-$99.00 $15.00
$99.01-and over $17.00
Revised 8-11-14
National Women of Achievement, Incorporated
Vendor Booth Agreement Form
PLEASE PRINT, THANKS!
Name________________________________________________________________________________
(First) (Middle) (Last)
Business Name________________________________________________________________________
Business Address____________________________________________ ZIP Code_________________
Telephone Number_________________________ Cell Number_________________________________
E-Mail Address________________________________________________________________________
DESCRIPTION OF ITEMS TO BE SOLD:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
CONFERENCE SITE:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
BOOTH RENTAL FEE $___________ Per Table
Number of Tables __________
Amount Enclosed __________
(Cashier’s Check or Money Order only) Make payable to: National Women of Achievement, Inc.
We do not provide food for Vendors. Tickets may be purchased from the National Financial
Officers for any day or evening activities. Prices vary for activities.
I AGREE TO ABIDE BY THE VENDOR AGREEMENT BOOTH AND DISPLAY GUIDELINES
_________________________________________________ ____________________________
Vendor Signature Date
Please return completed Vendor Booth Agreement Form to:
National Women of Achievement, Inc.
Financial Secretary
P. O. Box 14909
Houston, Texas 77221
Date Received to NWOA ___________________
Revised 8-14-14