*1.[REQUIRED] CHAPTER INFORMATION(Required.)

Reporting Year (e.g. 2022):

Official Incorporated Chapter Name:

Year of Incorporation:

State of Incorporation:

Chapter Home Institution:

Website url:

*2.[REQUIRED] Person Submitting this Report(Required.)

Full Name:

Chapter Role:

Email Address:

Phone Number:

*3.[REQUIRED] Chapter Leadership
Note: Please insert name and email address of your council or board leadership(Required.)

Chapter President:

Chapter President-elect:

Past-president:

Secretary:

Treasurer:

Chapter Advisory Committee (CAC) Representative:

Other(s) (list any council/board members not listed above: include name, role, email) (if none, enter n/a):

Nonprofit registered agent and contact (if none, enter n/a):