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Published by , 2015-03-05 01:21:35

Forms - NWOA

Forms - NWOA

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


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