HMA Chapter Application

Chapter Name:_______________________________________________________________________

Treasurer: ___________________________________________________________________________

Address:_____________________________________________________________________________

Income		Expenses
Local Membership Dues:
(if applicable)	$_______	Postage $_______
Workshop/Seminar Fees	$_______	Program Costs $_______
Contributions/Grants	$_______	Speaker Fees $_______
Other ___________	$_______	Resource material $_______
________________	$_______	Travel Expenses $_______
________________	$_______	Telephone/Fax $_______
________________ ________________ (Attach additional pages as needed) Total List below all accounts of the chapter. INSTITUTION 1._____________________________ 2._____________________________ 3._____________________________ 4._____________________________ 5._____________________________	$_______ $_______ $_______ TYPE ACCOUNT ________________________ ________________________ ________________________ ________________________ ________________________	Other ____________ $_______ Total $_______ ACCOUNT # BALANCE ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________

IF CHAPTER ASSETS EXCEED $2500, INCLUDE ACCOUNT STATEMENTS FOR ALL ACCOUNTS FOR THE PREVIOUS THREE MONTHS.