Louisiana Wildlife Federation

LOUISIANA WILDLIFE FEDERATION, INC.

AFFILIATE APPLICATION for 2017

The Louisiana Wildlife Federation (LWF) requires the following information in order to communicate effectively with its affiliates. Please complete all the requested information on this form for our records. LWF mainly communicates by email to reduce cost and paper, but may periodically send info through the mail.

Date Affiliate Dues of $125.00 enclosed

Name of Organization

Organization’s Address/P.O. Box Number

City/State Zip Code

If available, organization’s:

Email Website

Please complete the following contact information for your organization’s current officers (or attach a comprehensive list on a separate sheet). List the name, address, phone number(s), fax number and email address, if available, for each officer:

President:
Mailing Addr:
City/State/Zip:
Phone (hm):
Phone (cell):
Phone (fax):
Email: / V.P.:
Mailing Addr:
City/State/Zip:
Phone (hm):
Phone (cell):
Phone (fax):
Email:
Secretary:
Mailing Addr:
City/State/Zip:
Phone (hm):
Phone (cell):
Phone (fax):
Email: / Treasurer:
Mailing Addr:
City/State/Zip:
Phone (hm):
Phone (cell):
Phone (fax):
Email:

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Other Officer (title) If Applicable:
Name:
Mailing Addr:
City/State/Zip:
Phone (hm):
Phone (cell):
Phone (fax):
Email: / Other Officer (title) If Applicable:
Name:
Mailing Addr:
City/State/Zip:
Phone (hm):
Phone (cell):
Phone (fax):
Email:

REQUIRED– DELEGATE/ALTERNATE DELEGATE TO THE LWF CONVENTION

Each affiliate must list the names and contact information of its designated Delegate and Alternate Delegate to the Louisiana Wildlife Federation’s Annual Convention to be held August 2016. The sole purpose of the Delegate is to cast an affiliate’s final vote on resolutions at the General Assembly of the Annual Convention. The Alternate Delegate assumes this responsibility should the Delegate not be able to attend.

Delegate Name:
Mailing Addr:
City/State/Zip:
Phone (hm):
Phone (cell):
Phone (fax):
Email: / Alternate Delegate Name:
Mailing Addr:
City/State/Zip:
Phone (hm):
Phone (cell):
Phone (fax):
Email:

OPTIONAL – AFFILIATE REPRESENTATION ON THE LWF BOARD

If they so choose, each affiliate has the option to be represented on the LWF Board of Directors by a member it so designates to serve. Refer to the “2016 Louisiana Wildlife Federation Board of Directors Agreement and Disclosure” for requirements, responsibilities and expectations of an affiliate director. Contact the LWF office at 225/344-6707 if you have questions. Directors must sign this agreement.

(Optional-see above) Affiliate Director Name:

Mailing Addr:

City/State/Zip:

Phone (hm):

Phone (cell):

Phone (fax):

Email:

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Number of current members: ______. (Please provide a roster of members and their contact information, if available. This list is for our records only to verify LWF members, and will not be provided or sold to any other entity.)

The fiscal year of our organization is from ______to ______.

When and where are meetings held? (e.g., 2nd Tuesday every other month, 7pm, Ruston Recreation Center) ______

______

Is your organization incorporated? ______If yes, is this a non-profit organization recognized by the IRS under section 501(c) of the Internal Revenue Code? _____ Yes _____ No

If yes, what is the specific non-profit classification of the organization, e.g. 501(c)3? 4? 7? etc.

Classification ______Tax ID No. ______

Please list up to 3 of your top conservation/recreation issue priorities for the coming year that the LWF can be of assistance with:

1)

2)

3)

Please contact the LWF office if you would like a copy of the Louisiana Wildlife Federation’s Charter & By-Laws.

Please put the LWF on your mailing list (address below) to receive any organization correspondence and newsletters. Email correspondence can be sent to .

Completed by: ______

Title______

Reply To: Louisiana Wildlife Federation, Inc., P.O. Box 65239, Baton Rouge, LA 70896-5239. You can email the scanned form to and mail/deliver the check separately.

Policy for new organizations affiliating with LWF: A new affiliate that joins from January 1 to April 30 will be considered active and their membership dues apply through December 31. A new affiliate that joins from May 1 to December 31 will be considered active through December 31 of the following year. A previously-affiliated organization can be considered new if it has not been an affiliate member in previous 2 years.

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