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ASET Chapter Toolkit:

Guide to Organizing and Developing

an ASET Chapter

ASET Chapter Toolkit

Guide to Organizing and Developing an ASET Chapter

ASET-The Neurodiagnostic Society

402 East Bannister Road, Suite A

Kansas City, MO 64131-3019

816.931.1120 phone

816.931.1145 fax

www.aset.org

The ASET Chapter Toolkit has been developed to assist you and your fellow

neurodiagnostic technologists in forming an ASET chapter at the local, state or

regional level.

ASET - The Neurodiagnostic Society is the largest national professional association

for individuals involved in the study and recording of electrical activity in the brain

and nervous system. Organized in 1959, ASET has grown to over 4,000 members.

ASET's mission is to provide leadership, advocacy and professional excellence for

our members, creating greater awareness of the profession and establishing

standards and best practices to ensure quality patient care.

Neurodiagnostics includes but is not limited to: Electroencephalography (EEG),

Evoked Potentials (EP), Nerve Conduction Studies (NCS), Polysomnography/Sleep

Technology, Intraoperative Neurophysiological Monitoring (IONM), Long Term

Monitoring (LTM), and Intensive Care Unit Continuous EEG Monitoring (ICU/cEEG).

This toolkit contains valuable information that will help you

form a state or local chapter. The ASET staff is here to help

you as you take the steps necessary to form your chapter. If

at any time you have any questions about the material in

this manual or need an electronic copy of any documents in

the appendix, please contact the ASET Governmental &

Grassroots Advocacy Manager at 816-931-1120, ext. 105.

http://www.aset.org/


Introduction: About ASET

Section One: Establishing a Chapter

1. Forming a Steering Committee

2. Finding Neurodiagnostic Professionals in Your State

3. Sending a Survey to Potential Members

4. Processing Surveys

5. Organizational Meeting

6. Meeting Agenda

Section Two: Chapter Organization

1. Chapter Leadership

2. Naming the Organization

3. Mission Statement

4. Membership

5. Chapter Dues and Collection

Section Three: Your Chapter As A Business

1. Incorporation

2. Chapter Bylaws

3. Employer Identification Number

4. Non-Profit Status

5. Register to Do Business

6. Establishing A Bank Account

7. Record Keeping

8. Chapter Committees

Appendix List

A. Member Survey

B. Member Survey Tally Sheet

C. Member Date Base Spreadsheet

D. Invitation to Organizational Meeting

E. Organizational Meeting Agenda

F. Charter Meeting Agenda

G. Individual Membership Application

H. Institutional Membership Application

Table of Contents


I. Chapter Bylaws

J. IRS SS-4 EIN Instructions

K. IRS SS-4 EIN Form

L. Chapter Balance Sheet

M. Income and Expense Statement Template

N. Committee Chair Job Description

O. Committee Work Plan

P. Volunteer Enrollment Form

Q. Committee Member Policy


During its 2012 annual meeting the ASET Board of Trustees voted unanimously to

adopt a Chapter Affiliate program. Under the program local, state and regional

neurodiagnostic societies, and new neurodiagnostic grassroots organizations in

development, may petition ASET to be charted as an ASET chapter. The board’s

adoption of the Chapter Affiliate program was subject to endorsement by local,

state and regional neurodiagnostic society presidents present at the Presidents

Roundtable meeting held during the 2012 ASET Annual Conference. Those present

at the meeting unanimously endorsed Chapter Affiliate program. Societies

represented at the meeting included the Indiana Society of Electroneurodiagnostic

Technologists and Technicians, Tennessee Neurodiagnostic Society, Florida Society

of Neurodiagnostic Technologists, Michigan Electroneurodiagnostics Technologist

Society, Central Society of Electroneurodiagnostic Technologists, Illinois Society of

END Technologists, Mid-Atlantic Neurodiagnostic Society, Southern Society of

Electroneurodiagnostic Technologists, Western Society of Electroneurodiagnostic

Technologists, North Eastern Society of Electroneurodiagnostic Technologists, and

the Greater New Orleans Electroneurodiagnostic Association.

The ASET Board of Trustees adoption – and local, state and regional society

endorsement – of the Chapter Affiliate program was the culmination of two years of

development, including multiple cycles of reviews and comments by the local

neurodiagnostic societies and related stakeholders, and open discussion by ASET

members at the 2011 ASET Annual Business Meeting.

The Chapter Affiliate program as outlined in this document provides for the legal

formalization of relationships between ASET and local, state and regional

neurodiagnostic organizations. While nothing in the affiliate agreement or chapter

charter creates any association, joint venture, partnership, or agency relationship

between ASET and local societies, the program does identify certain corporate

formalities and tax and reporting obligations that local organizations must meet in

order to be charted as an ASET chapter. It also identifies the specific obligations

that ASET and its chapters have to each other. Even though there have always

been some shared memberships between the various entities, heretofore ASET and

all of the local societies operated independently of one another. For detailed

information on filing to become an ASET chapter refer to ASET Toolkit: Guide to

Organizing and Developing an ASET Chapter.

The purpose of this toolkit is to assist neurodiagnostic professionals in developing a

local, state or regional chapter of ASET - The Neurodiagnostic Society, with specific

focus on the initial organization, legal requirements and the business aspects of

creating and running the chapter. The expertise of ASET is available to provide you

Introduction


with the necessary guidance, document templates and models to help your chapter

achieve its full potential. We have elected to structure the process in a step-by-step

manner so your group can take your organization as far as appropriate for your

members. Keep in mind that organizing a local, state or regional chapter is not so

different from starting a new business—it requires three primary things: Planning,

Organization, Commitment.

PART I: This section provides information on establishing your chapter.

PART II: This section provides you details on organizing a chapter.

PART III: This section provides information on the business aspects of your

chapter.

APPENDIX: Here you will find templates and forms to assist you with the

development and continued growth of your chapter. The documents in

the Appendix are templates that may be customized to fit your specific

needs. They are merely a beginning point that will aid your chapter.

You may contact the Governmental & Grassroots Advocacy Manger at

ASET to obtain an electronic copy of any of the documents in the

Appendix.


ASET Mission Statement

ASET – The Neurodiagnostic Society provides leadership, advocacy and resources

that promote professional excellence and quality patient care in neurodiagnostics.

As a membership organization, ASET advances the profession by serving member

needs, defining and endorsing standards of practice, providing innovative

educational opportunities, promoting the profession, and building coalitions in allied

health and other communities of interest. Neurodiagnostics includes but is not

limited to Electroencephalography (EEG), Evoked Potentials (EP), Nerve Conduction

Studies (NCS), Polysomnography/Sleep Technology, Intraoperative

Neurophysiological Monitoring (IONM), Long Term Monitoring (LTM), and Intensive

Care Unit Continuous EEG Monitoring (ICU/cEEG).

ASET Vision Statement

ASET – The Neurodiagnostic Society is the premier membership organization of

professionals in the neurodiagnostic field. As the leader of the profession, we are

the catalyst for collaboration. As a result, patients receive the highest quality care

in neurodiagnostics, thus improving their health and well-being.

ASET Member Benefits

The value of ASET membership can be evaluated not only by the tangible benefits

you receive, but also by the practical guidance that is available to you through our

education programs, advocacy, publications, and member network. Here are just a

few advantages of a professional membership in ASET:

The Neurodiagnostic Journal

Free with your membership is a subscription to ASET’s quarterly, peer-reviewed,

Index Medicus listed journal full of research articles, case reports, review articles,

technique articles, and book reviews.

ASET News

Free with your membership is a subscription to the Society’s quarterly softcopy

newsletter, featuring technical tips Interest Section feature articles, and Society

news and events.

Online Education Portal

ASET’s online education portal is accessible 24x7 and offers courses in EEG, IONM,

NCS, EP and LTM.

About ASET-The Neurodiagnostic Society

http://www.aset.org/i4a/pages/index.cfm?pageid=3314


http://aset-edu.org/


Education Seminars

Offered in various cities throughout the year, ASET’s two-day education seminars

offer programming to strengthen skills, improve core competencies, explore new

ideas, and raise the level of group dialogue among participants.

Webinars

Combining audio, video, chat, and blackboard capability, ASET’s webinars offer you

an interactive learning environment via your computer and the Internet. A new

topic is offered every third Wednesday from January through May and from

September through November. Recordings of webinars are also available.

Annual Conference

The ASET Annual Conference is the largest educational opportunity and networking

event in the world for neurodiagnostic professionals and industry partners.

Continuing Education Credits

ASET-CEUs are awarded to programs that apply to ASET for this designation and

meet rigorous evaluation criteria.

Transcript Service

ASET maintains individuals’ ASET-CEU credits in its member database. As an ASET

member, you can log in on the ASET website and view or download your ASET-CEU

transcript 24/7.

Bookstore

ASET maintains an inventory of more than 50 titles of original works, reprints, and

publications available through reselling agreements for EEG, evoked potentials,

intraoperative neuromonitoring, nerve conduction studies, polysomnography, board

exam preparation, lab management, and reference and career information.

Online Member Directory

ASET’s online Membership Directory is an invaluable networking tool. Members can

search the directory by name, city, state, country, and Interest Section.

On-line Discussion Forums

ASET’s on-line discussion forums are organized by Interest Sections.

Legislative and Regulatory Resources

Dedicated to promoting the value of neurodiagnostics and technologists to elected

officials and regulators at the federal and state levels, ASET actively works to shape

legislation and regulatory proposals that affect the neurodiagnostic community.





http://www.aset.org/files/public/ACE_Transcript_Request_Form.pdf

http://www.aset.org/i4a/ams/amsstore/store.cfm?product_id=0

https://www.aset.org/i4a/ams/amslogin.cfm?nextpage=/i4a/pages/index.cfm?pageid=3391

http://www.aset.org/i4a/pages/Index.cfm?pageID=3499



Professional Standards and Best Practices

Through ASET’s committees and task forces, members work to develop professional

standards, best practices, and national competencies for the neurodiagnostic

modalities.

Employment Exchange

ASET’s online employment exchange includes both a listing of available positions

and a resume bank.

Scholarships and Grants

ASET members may apply to the ASET Foundation for scholarships to underwrite

registration for the Society’s education seminars and annual conferences. Grants

may be used to offset tuition cost of accredited neurodiagnostic programs and at

institutions of higher education.

Awards and Recognition

ASET believes in rewarding and recognizing its members for their service,

dedication, volunteerism, and contributions to the neurodiagnostic profession.

Group Insurance

ASET members, whether employed or self-employed, have the opportunity to

purchase professional liability insurance.


http://www.aset.org/i4a/careercenter/?pageid=3348&showTitle=1


https://www.chooseaflac.com/New/MainPage.aspx?Path=ASET


The ASET Chapter Affiliate program grants non-exclusive charters to established

local, state and regional neurodiagnostic societies as well as organizations under

development. Establishing and growing neurodiagnostic organizations at the local,

state and regional level has the potential to contribute to membership growth of the

national society and the chapters. Establishing a chapter will lead to improvement

of quality patient care by making continuing education opportunities more readily

available – and presumably more affordable – at the local level as well as

encouraging technologists who currently may be isolated to network with local

peers and outreach more often with the local chapter and the national society.

Strong neurodiagnostic organizations at the local, state and regional levels will help

build awareness and understanding of the neurodiagnostic profession to both the

institution and the patient populations. Chapters provide members information,

continuing education and timely communication allowing them the opportunity to

stay abreast of ever changing developments in the profession. The presence of a

viable and organized neurodiagnostic organization with credible membership

numbers in a given state will make it easier to marshal the forces to recognize and

amend proposed legislation, regulations and rules that have a negative impact on

the practice of the neurodiagnostic profession, and to advance legislation,

regulations and rules favorable to the profession.

There are additional reasons for starting a chapter, which meet a variety of needs,

including:

A venue for meeting, interacting with and sharing information with other area

neurodiagnostic professionals

The opportunity to work together as a team to influence public policy and

advocate on behalf of the profession

A means of staying abreast of the constantly evolving health-care industry

An open channel for the exchange of ideas and information

Increased and accessible educational opportunities

A centralized entity to enhance networking opportunities

Establishing a chapter requires a dedicated group of professions that are willing to

put in the time and effort to see their plans through to a successful end. Organizing

a chapter requires planning, organization and commitment. This step-by-step guide

will take you through the process of successfully establishing an ASET chapter.

Section One: Establishing an ASET Chapter


Step One: Forming a Steering Committee

The first step in forming an ASET chapter is to establish a Steering Committee. The

Steering Committee is instrumental in planning and organizing the efforts

necessary to fulfill the commitment of becoming a chapter. It takes only a few

dedicated, enthusiastic individuals to launch a local, state or regional chapter. It is

helpful if these individuals have demonstrated leadership experience and/or are

well known within their locality or state and thus able to recruit other

neurodiagnostic professionals with the necessary skills. A steering committee of

three to five individuals who are committed to the effort will provide a good starting

point.

Step Two: Finding Neurodiagnostic Professionals in Your State

The second step is to locate others who would be interested in becoming members

of an ASET chapter. Professionals including technologists working in hospitals,

physician offices, independent testing facilities, consulting services and

equipment/supply vendor businesses are likely candidates for membership. In

addition physicians, including neurologists and physiatrists, along with PhDs,

nurses, audiologists and other allied health professionals, are also potential

members of a chapter. ASET can provide you with a list of current ASET members

and prospects within your state as a starting point. It may be helpful to divide the

state into geographical sections and assign each member of the steering committee

a territory to canvass for potential members.

Step Three: Sending a Survey to Potential Members

The third step is to send a survey to potential members that will help gauge the

interest in forming a local or state chapter. As ASET’s prospect list may be limited,

you should also put together a list of facilities where neurodiagnostic procedures

are likely to be performed and businesses that may employ neurodiagnostic

professionals (hospitals, clinics, physician offices, equipment manufacturers, etc.).

A state-by-state list of hospitals can be found at: http://www.ahd.com/search.php

or by using any Internet search engine. A sample survey is available in the

Appendix.

Step Four: Processing Surveys

The next step in the process is to organize the surveys to maximize participation in

your organizational meeting. A member of the steering committee should be

assigned the responsibility of collecting and processing the returned surveys. From

the survey responses, you can develop a mailing list. It is helpful to compile this list

in a computerized format, such as Microsoft Excel or Access. As the mailing list

grows it can be easily manipulated as needed in the future, to send out mailings, to

http://www.ahd.com/search.php


track membership and dues payments, etc. An Excel spreadsheet database

template and survey tally sheet is included in the Appendix.

Step Five: Organizational Meeting

The fifth step is to hold an organizational meeting. Invitations to your

organizational meeting should include all the interested parties identified in your

initial survey. You may choose to expand your invitation to those who did not reply

to the survey as well, depending on the capacity of your meeting room. It is

recommended that you include an RSVP request (with deadline) to be certain you

have adequate space and refreshments (if provided) for all attendees. A meeting

site which is central in the state is a good idea to provide easy access from all parts

of the state. New chapters, with no initial startup funding, may seek a venue which

can be reserved at no cost to the group, such as a hospital or university meeting

room. Keep in mind the projected size of your group. Interested vendors may be

willing to help defray the cost of an organizational meeting in their territory.

A sample invitation to an organizational meeting is included in the Appendix.

Keep in mind that the original members can be designated “charter members” and

arrange for a group photo for historical purposes.

Step Six: Meeting Agenda

The agenda for the initial meeting will get the chapter off to a good start. An

agenda for the initial organizational meeting would likely include:

Deciding on a name for the society (please refer to Step Eight)

Development of Mission and Vision Statements

Development of the chapter’s charter (re: Bylaws/Articles of

Incorporation)

Appointment or election of temporary officers and board members

(these may be the same as the Steering Committee members – see

also Step Seven)

Determination of dues

Establishing a plan for future activities

o Membership drive

o Next meeting

You may want to consider using a trained facilitator to help with the initial

organizational meeting, if funds are available. Starting with introductions helps the

group get acquainted. Names, credentials, where each participant lives and works

and what they do, along with some other detail about themselves (perhaps how

they got into neurodiagnostic technology) will break the ice and help the group with


the decisions to be made later. It is important to assign someone as the temporary

secretary or recorder to take minutes until an official secretary is elected. A sample

agenda for organizational and charter meetings are included in the Appendix.

The next phase involves organizing the foundation of the chapter. Without a strong

foundation the chapter will not be able to grow and thrive. These foundational steps

are very important to insuring the success of your chapter.

Step Seven: Chapter Leadership

A key foundational step is the designation of officers. Some groups may decide to

go with a more formal nomination/election process while others may use a less

formal first appointment for the inaugural leaders. It may be best to ask for

volunteers to get those who are most interested working for the group. The survey

provided will allow you to identify potential leaders. Most groups will elect a

President, Vice-President (or President-elect), Secretary and Treasurer (or

Secretary-Treasurer). These officers may be installed and begin their duties

immediately. A Board of Directors, consisting of a specified number of members,

should then be formed and installed. Details on the Board of Directors are as

follows:

Financial Support and Benefits

a. Directors do not receive compensation for their services.

b. Members of the Board of Directors may receive complimentary

registration for the annual conference during their terms in office,

including those meals which are incorporated into the registration

fees.

c. In accordance with Chapter policy, reimbursement may be provided

for specific and reasonable expenses incurred while attending

additional board meetings or performing special duties as requested

by the President and for which other coverage or reimbursement is

not available.

The basic functions of the Board are as follows:

a. To propose, discuss and approve strategic goals for the Chapter

consistent with the mission of the chapter and ASET.

b. To ensure the necessary resources are available and utilized

efficiently

c. To assure significant progress and achievement of goals

d. To represent the interests of the Membership

Section Two: Chapter Organization


e. To act as the governing authority for the Chapter

The roles of the Board include:

a. The Corporate Role

i. Implementation of a strategic plan

iii. Oversight of the programs and resources of the Chapter

iv. Establishing internal operational policies

b. The Legislative Role

i. To identify and monitor issues of interest to the Membership

c. The Adjudicatory Role

i. Evaluate positions presented and:

1. Choose the best position

2. Compromise/create alternatives choices

3. Decide not to decide

d. These roles and functions require that the Board focus its time and

effort on direction setting, operational oversight, policy setting and

strategic thinking.

Step Eight: Naming the Organization

The name of the organization will tell the world who you represent. Organizations

charted by ASET as chapters shall bear the legal name: [name] Chapter of ASET –

The Neurodiagnostic Society. Organizations already incorporated under a different

legal name, and which are seeking chapter status should either file an amendment

to their articles of incorporation for the name change (and notify all states in which

they are registered (qualified) to do business accordingly), or file for a fictitious

name certificate. A permissible reference to the chapter name in text is “… the

[Name] Chapter of ASET – The Neurodiagnostic Society. An acceptable abbreviation

of the Chapter name in text is (2-letter state abbreviation) ASET Chapter. Example:

Florida Chapter of ASET – The Neurodiagnostic Society. Acceptable Abbreviation:

FLASET Chapter (Note: the word “Chapter” must always appear with the acronym).

Consider a logo for your group—if someone in your group has an artistic talent or

expertise in graphic design, they may volunteer to develop a unique logo for your

organization at no cost.

Step Nine: Mission Statement

A mission statement is a short, compelling, written statement of the purpose of the

organization. This statement will guide the actions of the group, spell out the

overall goals, provide a sense of direction and guide decision-making. The

statement provides the framework within which the organization’s strategies are

formulated. It should answer some specific questions:


What is the organization?

Why does it exist?

What does the organization do?

What does the organization want to be?

The mission statement is extremely valuable to your organization. It shapes, forms

and directs the purposes or reasons for existence of the organization. Time,

persistence, patience, creativity, refinement and compromise are required to

finalize the mission statement but the time will be well spent. The existence of a

mission statement will help in drafting the articles of incorporation, the bylaws and

guiding the future direction of the group. An Internet search of various mission

statements will provide you with examples to consider.

There should be a consensus among all stakeholders as to what the organization

will seek to accomplish and a brief description of the service, product or philosophy

as well as the members and constituencies to be served. Construction of your

mission statement should be an open discussion with all possible ideas and

suggestions given due consideration. There is no right or wrong length for a mission

statement, with some being quite succinct and others several pages long. The final

statement should be approved by a vote of the membership prior to being adopted.

As an example here is ASET’s Mission Statement: “ASET – the Neurodiagnostic

Society provides leadership, advocacy and resources that promote professional

excellence and quality patient care in neurodiagnostics. As a membership

organization, ASET advances the field by serving member needs, defining and

endorsing standards of practice, providing innovative educational opportunities,

promoting the profession, and building coalitions in allied health and other

communities of interest. Neurodiagnostics includes but is not limited to

Electroencephalography (EEG), Evoked Potentials (EP), Nerve Conduction Studies

(NCS), Polysomnography/Sleep Technology, Intraoperative Neurophysiological

Monitoring (IONM), Long Term Monitoring (LTM), and Intensive Care Unit

Continuous EEG Monitoring (ICU/cEEG).”

Step Ten: Membership

The classes of membership and dues schedule need to be determined. For some

groups, there may be only one type of membership, while larger or more diverse

groups may elect to have multiple types of membership, depending on the make-up

of the participants. This will be incorporated into the bylaws as they are developed.

If multiple classes of membership are developed a corresponding range of dues will

be necessary.


As a guideline here are the different membership types of ASET:

Active: Any person whose primary employment or training is in clinical practice,

research, education or management in neurodiagnostics may become an active

member. Any person holding Active membership in good standing shall be entitled

to all membership privileges including the right to vote, to hold office and

committee appointment and receive the official publications of the Society.

Associate: Any person who has an interest in neurodiagnostics who does not

qualify under the existing individual member categories may become an associate

member. Associate members in good standing shall be entitled to all membership

privileges, including the right to vote and to serve on committees, but shall not be

eligible to serve as a trustee or officer.

Student: Any person enrolled in a formal training program for neurodiagnostics not

including on-the-job training may become a student member. Such persons may

qualify for student memberships for the length of their educational program.

Student members shall receive official publications of the Chapter, may serve on

committees, and shall be eligible to vote, but shall not be eligible to serve as a

trustee or officer.

Institutional: Any health care delivery or educational institution which employs or

educates neurodiagnostic technologists may become an institutional member.

Institutional members in good standing shall be entitled to all membership

privileges, including the right to vote by the primary representative as designated

by the institution and to serve on committees, but shall not be eligible to serve as a

trustee or officer.

Corporate: While not an ASET member class; your organization may want to

consider forming a corporate member class as a way to enlist support from the

vendor and supplier community. For example: Any corporation or business which

provides a product or service to the neurodiagnostic profession and is interested in

advancing the chapter may become a corporate member. Corporate members in

good standing shall be entitled to serve on committees, but shall not be eligible to

serve as a director or officer.

Dual Membership

As adopted in the Chapter Affiliate program, it is the option of the individual and/or

institution to join ASET, an ASET Chapter, or both. An individual or institution is not

required to be a member of ASET in order to join a Chapter. Similarly, an individual

or institution does not need to join a Chapter in order to be eligible to be a member

of ASET. An individual and/or institution may opt to join one or more ASET

Chapters.


Availability of Services to Non-Members

Due to provisions of anti-trust laws, Association services considered to be of a

competitive benefit must be made available to non-members. The association may

charge a higher fee for the benefits offered. The association should make available

its services to customers and suppliers of participants and non-participants,

members and non-members. In the area of conferences, non-members should have

access to participation in the events. Associations should make publications

available to non-members and if advertising is allowed in such publications, non-

members should also be eligible for placement of advertisements. If associations

ordinarily provide membership lists and directories to members, they should make

them available to non-members.

An association does not necessarily have to solicit non-member participation in any

of its activities. However, it must grant access to specific services if such access is

requested by a non-member. In such cases, an association may charge the non-

member a reasonably higher price for the particular association service than it

charged for members.

Step Eleven: Chapter Dues and Collection

Each Chapter is empowered to set its member dues structure at a sufficient level to

fund and sustain its operations. However, if the Chapter opts to take advantage of

ASET’s chapter member enrollment and renewal program, then the Chapter

member year must be on the calendar year and provisions should be made for a

pro-rated dues structure for the first year of membership.

For Chapters taking advantage of the ASET Chapter Member Enrollment and

Renewal Program, it is recommended that Chapters establish a two-tiered dues

structure for each of its member classes. Tier one would be applicable to individuals

and institutions that opt to hold dual membership in ASET and the Chapter. The

second tier would be applicable to individuals and institutions opting to become a

member only of the Chapter. Under the tier one dues structure, the individual and

institution would be assessed a lower dues rate compared to individuals and

institutions opting to just join at the chapter level, thus providing an economic

incentive to join both the national and the chapter organization. Example member

application forms are available in the Appendix.

ASET Chapter Member Enrollment and Renewal Program

ASET’s membership database (internet4associations) has the ability to add chapter

membership as an option to the ASET membership application with dues rate (or

rates) as determined by each individual chapter. ASET and chapter dues payments

can be segregated for easy reporting of new and renewal dues to each organization.


To help grow chapter membership, and to eliminate some of the administrative

burden on the part of chapters to bill and collect for member dues, when a chapter

has been officially chartered by ASET, the Society will add that chapter and its dues

rates to the Society’s membership applications. Individuals and Institutions

submitting ASET member applications will have the option to join a chapter at the

time of application submission. For individuals who join both ASET and a chapter, at

the time of member renewal, ASET’s dues renewal notices will be modified to bill for

both national and the applicable chapter dues. At the time of renewal, members will

have the option to renew their ASET membership only, their dual (ASET and

chapter) membership, or their chapter only membership. Upon renewal, members

also will have the opportunity to change their chapter membership in the event

they relocate to a region outside of their original chapter territory.

It should be noted that for chapters utilizing two-tiered dues rates, renewal of

chapter-only membership thru ASET will likely result in utilization of the lower

membership dues rate.

Those chapters who participate in the ASET Chapter Member Enrollment and

Renewal Program will receive a monthly Excel spreadsheet via e-mail. This will

include the demographic and payment information on all chapter membership

and/or renewal applications and dues payments for the preceding month. In

addition, the chapter will receive quarterly payments for 100% of all chapter dues

collected by ASET during the preceding quarter.

Chapters participating in ASET’s Chapter Member Enrollment and Renewal Program

have the option to designate on their chapter membership applications that

individuals joining only at the chapter level submit their application and dues

payment directly to ASET for processing (either hardcopy or online). Chapters

opting to have ASET process its chapter-only member applications must work with

ASET in the development of those applications to ensure consistency in data

requested on the member application forms.

No later than September 30th of each year, chapters participating in the ASET

Chapter Member Enrollment and Renewal Program must submit their dues rate

structure for the coming year.

Complete contact and demographic information captured by ASET on the chapter

only member application will be included in the Excel spreadsheet emailed monthly

to the Chapter Secretary (or designee). Dues payments received by ASET from

chapter only member applications will be included in the quarterly payments sent to

the Chapter. The advantage to this is that it eliminates the need for the chapter to

maintain a member database and dues payment records, or greatly decreases the

amount of labor required on the part of the chapter to maintain its member list. For

those chapters that do not have the capability to accept member applications and


dues payments online, it also eliminates the need for chapters to obtain and enter

into merchant agreements to process charge card transactions and pay merchant

processing fees as those fees will be absorbed by ASET.


Step Twelve: Incorporation

In order to be eligible to become an ASET Chapter the organization must be

incorporated or have filed for incorporation. Available legal structures for

associations include corporation, unincorporated association and trust. Establishing

your chapter as a corporation provides several advantages including: officers,

directors, members and employees who act in good faith are, in general not

personally liable for association liabilities; there are designated lines of authority

and organization structure; the organization must operate within a carefully

conceived system of state law; and incorporation permits perpetual existence.

Disadvantages of not incorporating include: unincorporated associations, which are

rarely treated in detail by state statutes, are subject to much greater legal

uncertainty; individual liability of members is possible; and it is difficult to establish

entity status. Incorporated status is issued by the state government and designates

the corporate status (i.e. non-profit). An initial filing fee is generally required and

often an annual report with a renewal fee. An attorney can assist with the

incorporation process but most states provide information to allow individuals to

complete the required application without legal representation.

Indemnification

If an association is incorporated, members, officers and directors are not usually

liable to third parties for debts and obligations of the chapter. However, directors

and officers may be liable to third parties if an association is not adequately funded

and/or if actions are imprudent/grossly negligent or willful and result in liability to

the association. Further, directors and officers may be held liable for association

offenses that are personal violations, such as libelous statements and conspiracy to

violate antitrust laws.

Associations may indemnify officers, directors and employees against liabilities

arising out of actions taken in good faith. Indemnification may be voided if the

association dissolves. Indemnity and insurance must usually be obtained with

exclusions for antitrust violations, willful misconduct and violation of state or federal

laws prohibiting discrimination. Policies with antitrust coverage may be available.

Articles of Incorporation

Each state requires filing of the “Articles of Incorporation” which becomes the basic

governing document for the corporation. This is typically a simple form which

includes basic information such as the name of the corporation, the general

purposes, the board of directors, etc. The applicable Secretary of State office should

have forms which can be easily followed. The National Association of Secretaries

Section Three: Your Chapter as a Business


website will allow you to find your Secretary of State at:

http://www.nass.org/index.php?option=com_contact_display&Itemid=346

Step Thirteen: Chapter Bylaws

The next task to be tackled is the development of chapter bylaws. The bylaws

codify the rights and privileges of the chapter’s members and describe the

relationship between the chapter’s Board of Directors and its membership. They

serve as a guidepost for the work of all officers, committees and members. The

President may elect to assign someone to chair a Bylaws Committee or have the

board work on this important document. It is helpful to establish a deadline for an

initial draft to be completed for review, approval or revision. Generally bylaws will

need to be completed and approved before an application for incorporation can be

submitted to the state. A model chapter bylaws is included in the Appendix which

may be tailored to the individual chapter. Bylaws should include:

Definition of classes and eligibility for membership

Provisions for election of officers and board members

A description of the duties of the officers

Definition of board procedures

Establishment of standing committees and their operation

Establishment of meeting frequency and necessary quorum for decision

making

Means for amending the bylaws

Step Fourteen: Obtaining an Employer Identification Number

An important part of the incorporation process is to obtain an Employer

Identification Number (EIN) by filing IRS form SS-4. Even if your group does not

plan to have any paid employees, this number will be required for many activities,

including opening a bank account, obtaining educational grants and filing for non-

profit status with the IRS. You may find the instructions on obtaining an Employer

Identification Number at http://www.irs.gov/pub/irs-pdf/iss4.pdf and you may find

the form at http://www.irs.gov/pub/irs-pdf/fss4.pdf

Step Fifteen: Non-profit Status

Another step that must be taken is to file the proper paperwork to establish the

chapter’s non-profit status. There are several classes of non-profit status with the

Internal Revenue Service (IRS). Most neurodiagnostic chapters will likely apply for

designation as a 501(c) (6) organization. This code applies to business leagues,

chambers of commerce and trade associations. There is a wealth of information on

the IRS website, including the required forms: http://www.irs.gov/Charities-&-Non-


http://www.irs.gov/pub/irs-pdf/iss4.pdf

http://www.irs.gov/pub/irs-pdf/fss4.pdf

http://www.irs.gov/Charities-&-Non-Profits/Other-Non-Profits/Life-Cycle-of-a-Business-League-%28Trade-Association%29


Profits/Other-Non-Profits/Life-Cycle-of-a-Business-League-%28Trade-

Association%29

In order to obtain recognition of tax-exempt status under Section 501(c) (6) of the

Internal Revenue Code you must use Form 1024 or request to be included in ASET’s

IRS group exemption. You may find instructions on IRS Form 1024 at:

http://www.irs.gov/pub/irs-pdf/i1024.pdf and you may find the form at:

http://www.irs.gov/pub/irs-pdf/f1024.pdf. If your request to be included in ASET’s

IRS group exemption is approved, your chapter will not have to file separately for

tax exempt status. However, your chapter still will have to annually file separate

tax returns.

Keep in mind that the designation of 501(c)(6) does not mean that dues payments

and contributions to the chapter are tax-deductible but with accurate

documentation your chapter may be exempt from paying federal income tax under

section 501(c)(6) of the Internal Revenue Code. Even though your chapter may not

have a federal income tax liability, your chapter still will be required to file annual

tax returns. The amount of your annual chapter income will determine which IRS

tax you’re your chapter will need to file.

You may be required to file IRS form 990. You may find the instructions on IRS

Form 990 at http://www.irs.gov/pub/irs-pdf/i990.pdf and you may find the form at

http://www.irs.gov/pub/irs-pdf/f990.pdf. Effective for 2010 tax year filings, which

will be made in 2011 and later, there are new threshold amounts determining which

Form 990 must be filed by exempt organizations that are not private foundations.

Some nonprofits will be able to file simpler forms under the new thresholds.

Organizations with annual gross receipts of $200,000 or more and total assets of

$500,000 or more will be required to file the "long" Form 990. Organizations with

annual gross receipts of more than $50,000, but less than $200,000, and with total

assets less than $500,000, may choose to file the long form, but can choose to file

the shorter Form 990-EZ instead. Organizations with annual gross receipts normally

equal to or less than $50,000 can choose to file either Form 990 or Form 990-EZ,

but they can also choose to file a Form 990-N "postcard" return electronically. The

regulations and thresholds are subject to change yearly.

The Form 990 (or equivalent) must be filed by the 15th day of the 5th month

following the end of the chapter fiscal year (see current IRS regulations). These

forms must be available for public inspection on request. In order to accurately

account for chapter income, an income and expense statement and balance sheet

should be maintained. Templates for these spreadsheets are in the Appendix.

There are specific guidelines for groups which are designated as non-profit by the

IRS, particularly related to purposes of the group, corporate compliance policies



http://www.irs.gov/pub/irs-pdf/i1024.pdf

http://www.irs.gov/pub/irs-pdf/f1024.pdf

http://www.irs.gov/pub/irs-pdf/i990.pdf

http://www.irs.gov/pub/irs-pdf/f990.pdf


and lobbying activities, etc. Refer to the IRS website for current information and

consult legal counsel for clarification. Some of the most important IRS guidelines

the group must follow are:

1. Specify in its articles of incorporation that no part of the chapter’s net

earnings may inure to the benefit of any private shareholder, individual or

entity, and restrict the chapter’s managers or directors from approving

any transactions that benefit a closely connected third party in excess of

fair market value (except where the transactions are in furtherance of the

chapter’s tax-exempt purposes)

2. Limit activities to those that are for the improvement of the entire

profession and not undertake activities that only provide particular

services for individual persons or entities;

3. Not engage substantially in a regular business of a kind ordinarily carried

on for profit, even if the business is operated on a cooperative basis or

produces only sufficient income to be self-sustaining

4. Avoid engaging in substantial unrelated business activities that might

jeopardize the chapter’s tax-exempt status

5. Properly identify and account for net income received from a trade or

business regularly carried on by the chapter, which is not substantially

related to the tax-exempt purposes of the chapter

6. Properly identify and report the chapter’s lobbying activities for federal

tax purposes. (Note: The general rule governing lobbying by 501(c)( 6)

organizations requires that organizations either disclose to their members

the percentage of membership dues which are not deductible due to the

organization’s lobbying activities or pay a proxy tax on total lobbying

expenses.)

7. Include in membership applications, dues invoices and other forms

requesting payments or contributions a notice that states that

contributions, gifts or payments to the chapter are not tax deductible as

charitable contributions (in addition, such forms generally must contain

the required lobbying tax disclosure unless the disclosure is provided

separately or the organization elects to pay the proxy tax)

Step Sixteen: Register to Do Business

In order to do business in your state, you must register as a business with your

state. The vast majority of states assign the duty of business registration to the


Secretary of State. The National Association of Secretaries website will allow you to

find your Secretary of State at:


Check with your state on the specific requirements, but as a guideline the following

steps normally are required in order to register to do business:

1. Before drafting articles of incorporation, it is imperative that you check the

availability of the desired business name with the Secretary of State’s office.

2. Next you need to select the ownership type. The ownership type you will be

registering is a non-profit corporation.

3. You will need to provide information on your chapter; including: Legal name;

mailing address, physical location and telephone number.

4. You are required to provide information on the officers of the chapter.

5. If the chapter is going to sell any items it will need to apply for a sales/use

tax license.

Step Seventeen: Establishing a Bank Account

You will want to establish a bank account for your chapter. A tax identification

number will be required by the bank. Specific persons are designated as

signatories, generally the President and Treasurer at a minimum, and are allowed

to conduct banking business. When officers change, these signatories must also be

changed with the banking institution. The bank may request a copy of meeting

minutes which reference the decision to open a bank account and who has been

designated as signatories. All income generated in your Chapter should be

deposited in the Chapter checking account.

Step Eighteen: Record Keeping

With the reporting that is required by state and federal law it is imperative that

each chapter maintain business records. It is best to keep accurate financial records

which will make it easier to fulfill the requirements of state and federal regulations.

A Balance Sheet and Statement of Income and Retained Earnings are included in

the Appendix which may be tailored to the individual chapter. Below are some

guidelines:

Corporate records (Articles of Incorporation; bylaws, including all

amendments minutes of all board, executive committee and membership

meetings; all reports filed with the state). These records should be kept on a

permanent basis.



Tax records (all tax information, returns and correspondence with federal,

state or local tax authorities). These records should be kept for a minimum of

seven (7) years.

Financial records (budgets, balance sheets, financial statements, bank

statements, cancelled checks). Maintain for minimum of seven (7) years.

Insurance records (policies and documentation related to claims). Maintain

for six (6) years.

Contracts (written contracts, such as with meeting facilities). Retain for

minimum of three (3) years following completion of the contract.

Step Nineteen: Chapter Committees

Finding dedicated members who are willing to devote time and expertise to serving

on a chapter committee will make a tremendous impact on the organization. Most

committees will require only a nominal time commitment from members but

enormous benefit will be derived from a diverse point of view. Some of the

committees which you may want to form include:

Membership Committee: Promotes and develops recruitment and

retention programs. Recommends programs and services to benefit

membership.

Bylaws Committee: Develops bylaws that codify the rights and privileges

of the chapter’s members and describe the relationship between the

chapter’s Board of Directors and its membership.

Nominating Committee: Receives and solicits nominations; reviews

nominee qualifications and prepares official slate; recommends policies and

procedures relating to the nominating process.

Finance Committee: Responsible for managing and maintaining the

finances of the Chapter along with fund raising, cash flow management,

income and expense management plus budgeting and growth initiatives.

Government Advocacy Committee: Creates partnerships with key

stakeholders, establishes new lines of communication with policy-makers

and extends outreach to public policy discussions.

Communications Committee: Communicate the activities and events of

the Chapter both internally, and to all external stakeholders. The

Committee is also responsible for producing the Chapter newsletter and

distributing it to all key stakeholders on a regular basis.

Education Committee: Plans strategic initiatives for educational

programming and professional development.

Policy & Procedure Committee: Develop, maintain and recommend to the

Board of Directors policies and procedures that will serve to support the

over goals and objectives of the Chapter.


Program/Annual Conference Committee: Coordinates all events and

programs that the Chapter hosts for its members. Committee is

responsible for the planning and logistics associated with Annual

Conference.

It is helpful if each committee is given specific guidelines about their role, duties

and goals. They may want to develop their own committee mission statement

which should be complimentary to the chapter’s statement. The following

documents found in the Appendix will help you as you develop your committee

structure:

Developing a Committee Work Plan

Volunteer Recruitment Form

Committee Chairperson Job Description

Committee Member Policy

Appendix A-Member Survey

20## (Insert State) Chapter of ASET – The Neurodiagnostic Society Member Survey

Thanks for taking the time to complete this questionnaire. Please enter your responses below.

Chapter Member Activities

1. The following is a list of activities members may experience when they join an ASET

Chapter. Please choose what programs would you like to be developed by the chapter and

rank them 1 to 5. With 1 being the most valuable chapter activity.

Annual Conference Dinner Meetings

Continuing Education Credits Education Seminars

Legislative Advocacy Member/Social Outings

Membership Directory

2. What are the primary reason(s) that you would consider belonging to the (Insert State)

Chapter of ASET – The Neurodiagnostic Society? (check all that apply)

To benefit from representation of the profession to legislators and regulators

To meet with and strengthen relationships with professional partners

To network with my peers in the profession

To gain access to research and profession statistics

To gain profession-specific education and training

To gain profession news and information

To support the profession

Other reason (specify)

3. What is your preference for receiving correspondence regarding chapter meetings,

upcoming events, etc.?

Hard Copy E-Mail Fax

Chapter Meetings

4. How often should your Chapter meet outside of the annual conference? Should it

meet…?(Select One)

Monthly Year-Round

Bi-Monthly Year-Round

Quarterly Year-Round

Monthly September-June

Bi-Monthly September-June

Quarterly September-June

5. When should your Chapter meet? Should it meet….(Select One)

Weekday Breakfast Meetings Weekday Luncheon Meetings

Weekday Dinner Meetings Weekday Late Afternoon (4PM Start)

Other (Please Specify)_____________________________________________________

6. What meeting sequence do you prefer? Do you prefer….(Select One)

Speaker, Meal, Networking Meal, Speaker, Networking

Networking, Speaker, Meal Networking, Meal, Speaker



Member Survey Page 2

7. What meeting format do you prefer? Do you prefer….(Select One)

Roundtables Panel Discussions

Guest speakers


Chapter Leadership

8. Using a scale of 1 to 5 where 1 is Not At All Willing and 5 is Very Willing. How willing are you

to help organize Chapter Activities and Events. (Circle One)

Not At All Willing Very Willing

1 2 3 4 5

9. Again using a scale of 1 to 5 where 1 is Not At All Willing and 5 is Very Willing. How willing

are you to serve in a Chapter leadership position. (Circle One)


1 2 3 4 5

10. Are you willing to serve as a Chapter:

Yes No Don’t Know

Committee Member

Committee Chair

Board Member

Chapter Officer

11. Would you be interested in becoming active in the Chapter in the future?

Yes No Maybe

12. How can chapter meetings be made valuable to you?

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

13. How can the Chapter help you show the value of continuing education credits to your

employer?

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________


Member Survey Page 3

Communications

14. In general, how do you prefer to receive communications from the (Insert State) Chapter

of ASET – The Neurodiagnostic Society? (please rank your preferences

"#1" = your top choice,, "#2" = your second choice, "#3" = your third, and so on)

RANK

_______ A. E-mail _______ B. Social Media _______ C. Web site _______ D. Newsletters

_______ E. Mail _______ F. Telephone

_______ G. Other method (specify) _____________________

15. Where do you use the following on a regular basis? E-mail: At home At work Both at home and at work Neither

Internet: At home At work Both at home and at work Neither

Other Organizations and Service Providers

16. Do you regard ASET – The Neurodiagnostic Society as your primary professional affiliation? Yes No If NO, what other organization is primary? _____________________________

17. What services from other organizations do you find most valuable?

18. In general, what are your favorite sources of industry news and information, from any

provider?

Social Media (specify):

Web Sites (specify URLs/addresses):

Conferences (specify events):

Employment Information

19. Which modality/modalities do you perform? (Check all that apply)

EEG EP ICU Monitoring IONM LTM MEG

NCS PSG Autonomic Testing

Name:___________________________________________________________

Work Phone #:_______________________ Fax #:_______________________

Email Address:____________________________________________________

(Please print contact information)

Appendix B-Member Survey Talley Sheet

20## (Insert State) Chapter of ASET – The Neurodiagnostic Society Member Survey

Survey Response Tally Sheet: Add up numbers and insert them in space provided before each

item.

Chapter Member Activities

1. The following is a list of activities members may experience when they join an ASET

Chapter. Please choose the 5 most valuable to you and rank them 1 to 5. With 1 being the

most valuable chapter activity. Average Score: Total score divided by number of responses

_____Annual Conference _____Dinner Meetings

_____Continuing Education Credits _____Education Seminars

_____Legislative Advocacy _____Member/Social Outings ______Membership Directory

2. What are the primary reason(s) that you would consider belonging to the (Insert State)

Chapter of ASET – The Neurodiagnostic Society? Average Score: Total score divided by number of

responses

_____ To benefit from representation of the profession to legislators and regulators

_____ To meet with and strengthen relationships with professional partners

_____ To network with my peers in the profession

_____ To gain access to research and profession statistics

_____ To gain profession-specific education and training

_____ To gain profession news and information

_____ To support the profession

______Other reason

3. What is your preference for receiving correspondence regarding chapter meetings,

upcoming events, etc.? Insert number of responses.

_____ Hard Copy _____ E-Mail _____ Fax

Chapter Meetings

4. How often should your Chapter meet outside of the annual conference? Should it

meet…?(Select One)

_____ Monthly Year-Round

_____ Bi-Monthly Year-Round

_____ Quarterly Year-Round

_____ Monthly September-June

_____ Bi-Monthly September-June

_____ Quarterly September-June

5. When should your Chapter meet? Should it meet….( Insert number of responses)

_____ Weekday Breakfast Meetings _____ Weekday Luncheon Meetings

_____ Weekday Dinner Meetings _____ Weekday Late Afternoon (4PM Start)

_____ Other

6. What meeting sequence do you prefer? Do you prefer….( Insert number of responses)

_____ Speaker, Meal, Networking _____ Meal, Speaker, Networking

_____ Networking, Speaker, Meal _____ Networking, Meal, Speaker

_____ Other


Member Survey Tally Sheet Page 2

7. What meeting format do you prefer? Do you prefer….(Insert number of responses)

_____Roundtable _____Panel Discussions

_____ Guest speakers _____Other (Please

Chapter Leadership

8. Using a scale of 1 to 5 where 1 is Not At All Willing and 5 is Very Willing. How willing are you

to help organize Chapter Activities and Events. (Develop list of those willing)


1 2 3 4 5

Average Score: Total score divided by number of responses = Average of__________

9. Again using a scale of 1 to 5 where 1 is Not At All Willing and 5 is Very Willing. How willing

are you to serve in a Chapter leadership position. (Develop list of those willing)


1 2 3 4 5

Average Score: Total score divided by number of responses = Average of__________

10. Are you willing to serve as a Chapter: (Insert number of responses, develop yes list)

Yes No Don’t Know

Committee Member ___ ___ ___

Committee Chair ___ ___ ___

Board Member ___ ___ ___

Chapter Officer ___ ___ ___

11. Would you be interested in becoming active in the Chapter in the future? (Insert number of

responses, develop yes list)

_____Yes _____No _____Maybe

12. How can chapter meetings be made valuable to you? (Create separate document with

comments)

13. How can the Chapter help you show the value of continuing education credits to your

employer? (Create separate document with comments)


Member Survey Tally Sheet Page 3

Communications

14. In general, how do you prefer to receive communications from the (Insert State) Chapter

of ASET – The Neurodiagnostic Society? (Insert total number of responses:

"#1" = your top choice,, "#2" = your second choice, "#3" = your third)

RANK

1st____ 2nd_____ 3rd____E-mail 1st____ 2nd_____ 3rd____Social Media

1st____ 2nd_____ 3rd____Web site 1st____ 2nd_____ 3rd____Newsletters

1st____ 2nd_____ 3rd____Mail 1st____ 2nd_____ 3rd____Telephone

1st____ 2nd_____ 3rd____Other method

15. Where do you use the following on a regular basis? (Insert number of responses)

E-mail: _____At home _____At work _____Both at home and at work _____Neither

Internet: _____At home _____At work _____Both at home and at work _____Neither

Other Organizations and Service Providers

16. Do you regard ASET – The Neurodiagnostic Society as your primary professional

affiliation? ____Yes ____No

(Insert number of responses)

17. What services from other organizations do you find most valuable?(Create separate

document with comments)

18. In general, what are your favorite sources of industry news and information, from any

provider?

Social Media(specify): (Create separate document with comments)

Web Sites (specify URLs/addresses): (Create separate document with comments)

Conferences (specify events): (Create separate document with comments)

Employment Information

19. Which modality/modalities do you perform? (Insert number of responses)

_____EEG _____EP ____ICU Monitoring _____IONM _____LTM _____MEG

_____NCS _____PSG _____Autonomic Testing

Name:___________________________________________________________

Work Phone #:_______________________ Fax #:_______________________

Email Address:____________________________________________________

*Create excel or access spreadsheet with all the member information

Appendix C-Member Data Sheet (ST) Chapter of ASET-The Neurodiagnostic Society

Member Data Sheet

First Name Last Name Credentials Company address1 address2 City State

Bob Johnson R. EEG T.,CNIM Cottage Hospital 900 North Seminary Street Galesburg IL

Mary Jones R. EEG/EP T.,CNIM,CLTM St. Mary's Hospital 1234 West Main St. San Franciso CA

Susan Smith R. EEG T. University Hospital 987 North Pleasant St. Kansas City MO

12/3/2012


Member Data Sheet

Zip Member Class Active Prospect Dues Amt Pd Pate Paid M.O.P. Degrees dateJoined email

61401 Active Y 40.00$ 6/1/2012 Credit Card AS 6/30/2012 [email protected]

94555 Associate Y 40.00$ 1/12/2012 Check BS 5/29/2012 [email protected]

64131 Active Y 40.00$ 3/15/20102 Check AA 2/14/2012 [email protected]

12/3/2012

mailto:[email protected]




Member Data Sheet

c_user_advocacy_emails Date of Birth Gender PreferredCommunication Fax Phone

Yes 6/25/1954 Male email 309-343-0000 309-343-0010

Yes 3/28/1978 Female mail 708-243-9000 708-243-9001

Yes 3/24/1957 Female fax 816-973-1120 816-973-1121

12/3/2012

Appendix D-Invitation to Organization Meeting

[Type text]

You are invited to an Organizational

Meeting to discuss the possibility of

forming an ASET Chapter

Come and join other neurodiagnostic professionals to learn about the

benefits of forming an ASET Chapter. There will be food, drinks,

conversation and fun.

When:

Time:

Where:

*RSVP before <date> by contacting<name> at <phone number>

or at <email> or by faxing this form to <fax>

Yes! I plan on attending and learning more about forming an ASET Chapter. Please send advance

materials on the meeting and association to:

Name:_____________________________________

Address:___________________________________

City:__________________State:____ Zip:________

Phone #:___________________________________

Email Address:_______________________________

Appendix E-Organizational Meeting Agenda

(name of state) Neurodiagnostic Chapter Organizational Meeting

Organizational Meeting Agenda

(Date of meeting)

(Place of meeting)

I. Call to Order/Introduction of steering committee (facilitator if present) a. Assignment of temporary secretary to take minutes

II. Overview of neurodiagnostic profession in state of (name of state) a. Results of initial interest survey

b. Roundtable introductions III. Review of Purpose of Chapter

a. Review of Reasons for Establishing Chapter

IV. Discussion a. Membership Classes, rights and privileges

b. Board of Directors, composition, method of nomination and election c. Annual Membership Conference

d. Bylaws/Articles of Incorporation e. Dues

V. Activities/Member Projects and Services

VI. Discussion of Standing Committee Members a. Membership Committee

b. Bylaws/Articles of Incorporation Committee c. Nominating Committee d. Program/Annual Conference Committee

e. Additional Committee Formation (Finance/Government) Advocacy/Communications/Education/Policy & Procedures)

VII. Solicitation of Committee Chairs and Members VIII. Date of next meeting

Appendix F-Charter Meeting Agenda

(name of state) Neurodiagnostic Chapter Charter Meeting

Charter Meeting Agenda

(Date of meeting)

(Place of meeting)

I. Call to Order II. Discussion

a. Member Programs, Services and Benefits i. Identification and prioritization

ii. Timetable and implementation III. Committee Reports

a. Membership Committee

b. Bylaws/Articles of Incorporation Committee c. Nominating Committee

d. Program/Annual Conference Committee e. Additional Committee Formation (Finance/Government

Advocacy/Communications/Education/Policy & Procedures) IV. Membership Promotion V. Election of officers (consider designating as interim until membership

established) VI. Adoption of Articles of Incorporation

VII. Adoption of Bylaws VIII. Adoption of Chapter Petition

IX. Activities

X. Date of next meeting

Appendix G-Individual Membership Application

INSERT LOGO To apply for membership, return completed application with payment by mail or by fax. (ST) Chapter of ASET membership is from January through December. First-year dues are pro-rated based on join date. For individuals joining October through December, membership runs through December of the following year.

Please check membership type: Jan – March April – June July – Sept. Oct. – Dec. Join Date Join Date Join Date Join Date

ACTIVE MEMBERSHIP $$$US $$$ US $$$ US $$$ US Individual whose primary employment or training is in clinical practice, research, education, or management in neurodiagnostics ASSOCIATE MEMBERSHIP $$$ US $$$ US $$$ U.S. $$$ US Interested person other than ND technologist STUDENT MEMBERSHIP $$$ US $$$ US $$$ U.S. $$$ US Individual residing in the U.S. and enrolled in a formal neurodiagnostics training program, not including on-the-job training. Application must be accompanied with letter from the school’s program director confirming student enrollment status and graduation date.]

CORPORATE MEMBER DUES* $$$ US $$$ US $$$ U.S. $$$ US Corporation or business which provides a product or service to the neurodiagnostic profession.

Last Name: ____________________________________ First Name: _______________________________ Middle: _________________ Sponsor’s Name/Who Introduced You to (ST) Chapter of ASET? ______________________________________________________ Check appropriate credentials, if any: R. EEG T. R. EP T. RPSGT CNIM R.NCS.T. CNCT CLTM Other __________________________________________

Check appropriate degrees, if any: 2 year Associates Degree BA BS MA MS MEd PhD Other ______________________________________________ Business Address: Company/Institution: __________________________________________________________________________________________ Street Address: ____________________________________________________________ City: _________________________________________

State/Province: ___________________________________ Zip/Postal Code: _________________________ Country: ______________________ Business Phone: [_______]______________________________ Business fax: [_______]_____________________________________ Home Address: Street Address: ____________________________________________________________ City: _________________________________________

State/Province: ___________________________________ Zip/Postal Code: _________________________ Country: ______________________

Home Phone: [_______]____________________

Preferred mailing address: Home Business

Section I: Membership Category

Section II: Applicant Information (Active/Associate/Student)

(ST) Chapter of ASET – The Neurodiagnostic Society Address

City, State Zip Tel: ###.###.#### * Fax: ###.###.##### * email

20## INDIVIDUAL MEMBERSHIP APPLICATION

STAFF USE ONLY: Office Code: Web Date Rec’d ________ Date Entered ________ By ________

Membership information is included in (ST) Chapter membership directory. However, we recognize the importance of your privacy and provide you with options relating to your listing. If no option is selected, your name will be included in the member directory.

My information as noted above, can be included in the member directory. My information is not to be included in the member directory.

Optional Information: What is your predominant professional activity?

Ambulatory EEG EEG ERG IOM/EEG Lab Management Pediatrics SSEP

BAEP ENG ICU/cEEG IOM/EMG LTME PSG VEP Biofeedback EOG Independent Contractor IOM/EP NCS Research Autonomic Testing

New Federal regulations by the FCC now require (ST) Chapter to have your permission before we can communicate with you via fax or e-mail about the important products, programs or services that you value the most. I hereby give (ST) Chapter of ASET this _____ day of _______________, 20_____ written permission to sent notices, advertisements, announcements, brochures, invoices and other information from ASET via facsimile and /or e-mail at the number and address shown herein. This permission will have no date of expiration.*

Signature _______________________________________________ Date ____________________

On occasion, (ST) Chapter of ASET may rent member mailing addresses and e-mail addresses to its business associates and third-parties for marketing purposes. If you would like to be included in these communications, please check each item that applies:*

Business associates/third-party mail

Business associates/third-party e-mail

* You may opt-out from receiving communications from (ST) Chapter of ASET and/or its business associates in the future by logging on to the Members Only section of the (ST) Chapter of ASET website and changing your communication preferences.

Check or Money Order payable to (ST) Chapter [payment must be in US dollars drawn on a US bank]

American Express Discover MasterCard Visa

Name on Card_______________________________________________________________

Account No _____-_____-_____-_____ Expiration Date________ / ________ Billing Zip Code__________________ CID____________________ Month Year

Cardholder Signature___________________________________________________________________________ $_______ TOTAL ENCLOSED** made payable to (ST) Chapter ASET – The Neurodiagnostic Society [Federal Tax ID#####]

**Dues payments and contributions to the (ST) Chapter of ASET General Operations Fund cannot be deducted as charitable contributions for federal income tax purposes. Payments may be partially deducted as an ordinary and necessary business expense. Subscription portion of dues: Active/Associate members $XX. For the remaining dues, the portion used for lobbying activities is approximately $X. The lobbying portion of your dues is not tax deductible.

Section III: Membership Listing

Section V: Payment Information

Section IV: Communication Consent

Appendix H-Institutional Membership Application

INSERT LOGO To apply for membership, return completed application with payment by mail or by fax. (ST) Chapter of ASET membership is from January through December. First-year dues are pro-rated based on join date. For individuals joining October through December, membership runs through December of the following year.

Jan – March April – June July – Sept. Oct. – Dec. Join Date Join Date Join Date Join Date

INSTITUTIONAL MEMBERSHIP $$$ US $$$ US $$$ US $$$ US Health care delivery or educational institutions which employ or educate electroneurodiagnostic technologists. (Dues include membership for one voting representative/ primary billing contact, and up to four additional employees.) EACH ADD-ON EMPLOYEE $$$ US $$$ US $$$ US $$$ US Institutions may enroll more than the five employees included in the base Institutional member dues at the add-on rate per additional employee indicated herein.

Organization Name: _________________________________________________________________________________________________________ Business Mailing Address: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ City: ________________________ State/Province: _______________ Zip/Postal Code: _______________ Country: ______________________ Business Phone: [_______]______________________________ Business Fax: [_______]____________________________________ Number of Neurodiagnostic Technologists Employed by Institution: _____________________________________________________________ Please identify the Institutional employee to serve as the voting representative and billing contact. This individual will receive the Institutional member subscription to the (ST) Chapter of ASET newsletter, and will receive an individually-assigned (ST) Chapter of ASET ID number, member log-in, and password for accessing the Members Only section of the (ST) Chapter of ASET website and to qualify for member rates on (ST) Chapter of ASET training courses, products and services. Primary voting representatives may serve on (ST) Chapter of ASET committees, but are not eligible to serve as a trustee or officer of the Chapter (unless they upgrade their membership to the Active member class). Last Name: ____________________________________ First Name: _______________________________ Middle: _________________ E-Mail: ___________________________________________ * Required field. Representative’s log-in and password to access the Members Only pages of the (ST) Chapter of ASET website will be automatically assigned and e-mailed to him/her upon approval of application. Representative may change his/her log-in and password at any time thereafter. Check appropriate credentials, if any: R. EEG T. R. EP T. RPSGT CNIM R.NCS.T. CLTM Other _________________________________________________

Check appropriate degrees, if any: 2 year Associates Degree BA BS MA MS MEd PhD Other _____________________________________________

Statistical data/Information: Date of Birth _______/_______/_______ Male Female (Note: This information is for (ST) Chapter of ASET internal use only for matching and maintaining individual ACE credit records. It is NOT published.) Membership information is included in (ST) Chapter of ASET membership directory. However, we recognize the importance of employee privacy and provide employees with options relating to their listing. If no option is selected, membership information will be included in the member directory.

Information as noted above can be included in the member directory. Information is not to be included in the member directory.

Section I: Member Dues

Section II: Applicant Information

20## INSTITUTIONAL MEMBER APPLICATION

Section III: Voting Representative/Primary Billing Contact Information

(ST) Chapter of ASET – The Neurodiagnostic Society Address

City, State Zip Tel: ###.###.#### * Fax: ###.###.##### * email



BAEP ENG ICU/cEEG IOM/EMG LTME PSG VEP

Biofeedback EOG Independent Contractor IOM/EP NCS Research Autonomic Testing

In addition to the Voting Representative/Primary Billing Contact, up to four more employees may be enrolled under an Institutional membership at no additional cost. Each employee enrolled will receive an individual subscription to (ST) Chapter of ASET newsletter, and will receive an individually-assigned (ST) Chapter of ASET ID number, member log-in, and password for accessing the (ST) Chapter of ASET website and to qualify for member rates on (ST) Chapter of ASET training courses, products and services. Institutional employee members may serve on (ST) Chapter of ASET committees, but are not eligible to vote or serve as a trustee or officer of the Chapter (unless they upgrade their membership to the Active member class). In the event of employment changes and/or new hires, an Institution may add employees to its Institutional membership, transfer an employee’s membership to another employee, or inactivate an employee’s membership, at any time throughout the year simply by notifying the (ST) Chapter of ASET. EMPLOYEE 1: Last Name: ____________________________________ First Name: _______________________________ Middle: _________________ Mailing Address if different than Institution mailing address: Street Address: ____________________________________________________________ City: _________________________________________


Business Phone: [_________]__________________________ Home Phone: [_______]_____________________________________________ E-Mail: ___________________________________________ * Required field. Employee log-in and password to access the Members Only pages of the (ST) Chapter of ASET website will be automatically assigned and e-mailed to the employee upon approval of application. Employee may change his/her log-in and password at any time thereafter. Check appropriate credentials, if any: R. EEG T. R. EP T. RPSGT CNIM R.NCS.T. CLTM Other _________________________________________________

Check appropriate degrees, if any: 2 year Associates Degree BA BS MA MS MEd PhD Other ____________________________________________

Statistical data/information: Date of Birth _______/_______/_______ Male Female (Note: This information is for (ST) Chapter of ASET internal use only for matching and maintaining individual ACE credit records. It is NOT published.) Membership information is included in (ST) Chapter of ASET’s membership directory. However, we recognize the importance of employee privacy and provide options relating to their listing. If no option is selected, employee’s name will be included in the member directory.

Employee information as noted above can be included in the member directory. Employee information is not to be included in the member directory.





EMPLOYEE 2: Last Name: ____________________________________ First Name: _______________________________ Middle: _________________ Mailing Address if different than Institution mailing address: Street Address: ____________________________________________________________ City: _________________________________________




Statistical data information: Date of Birth _______/_______/_______ Male Female (Note: This information is for (ST) Chapter of ASET internal use only for matching and maintaining individual ACE credit records. It is NOT published.) Membership information is included in (ST) Chapter of ASET’s membership directory. However, we recognize the importance of employee privacy and provide options relating to their listing. If no option is selected, employee’s name will be included in the member directory.

Section IV: Employee Member Information



Ambulatory EEG EEG ERG IOM/EEG Lab Management Pediatrics SSEP BAEP ENG ICU/cEEG IOM/EMG LTME PSG VEP





















Institutional members may enroll more than the five employees covered by the base Institutional member dues at the add-on employee rate listed herein. There is no limit to the number of employees that an Institutional member may enroll. Each additional employee enrolled will receive an individual subscription to (ST) Chapter of ASET newsletter, and will receive an individually-assigned (ST) Chapter of ASET ID number, member log-in, and password for accessing the Members Only section of the (ST) Chapter of ASET website and to qualify for member rates on (ST) Chapter of ASET training courses, products and services. Institutional employee members may serve on (ST) Chapter of ASET committees, but are not eligible to vote or serve as a trustee or officer of the Society (unless they upgrade their membership to the Active member class). For each add-on employee, please complete the following information. Please duplicate this section and attach to this application if more than one add-on employee is being enrolled. Add-on Employee 1: Last Name: ____________________________________ First Name: _______________________________ Middle: _________________ Mailing Address if different than Institution mailing address: Street Address: ____________________________________________________________ City: _________________________________________



Check appropriate degrees, if any: 2 year Associates Degree BA BS MA MS MEd PhD Other ____________________________________________

Statistical data/information: Date of Birth _______/_______/_______ Male Female (Note: This information is for (ST) Chapter of ASET internal use only for matching and maintaining individual ACE credit records. It is NOT published.) Membership information is included in (ST) Chapter of ASET’s searchable membership directory. However, we recognize the importance of employee privacy and provide options relating to their listing. If no option is selected, employee’s name will be included in the member directory.





New Federal regulations by the FCC now require (ST) Chapter of ASET to have permission before we can communicate with Institutional member employees via fax or e-mail about important products, programs or services. I hereby give (ST) Chapter of ASET this _____ day of _______________, 20_____ written permission to send notices, advertisements, announcements, brochures, invoices and other information from ASET via facsimile and /or e-mail at the numbers and address shown herein. This permission will have no date of expiration.*

Signature _______________________________________________ Date ____________________

On occasion, (ST) Chapter of ASET may rent member mailing addresses and e-mail addresses to its business associates and third-parties for marketing purposes. If you would like to be included in these communications, please check each item that applies:*

Business associates/third-party mail

Business associates/third-party e-mail

* Institutional employee members may opt-out from receiving communications from (ST) Chapter of ASET and/or its business associates in the future

by logging on to the Members Only section of the (ST) Chapter of ASET website and changing their communication preferences.

Section VI: Communication Consent

Section V: Add-on Employee Member Information

Check or Money Order payable to (ST) Chapter of ASET, Inc. [payment must be in US dollars drawn on a US bank]

American Express Discover MasterCard Visa

Name on Card________________________________________________________________________

Account No - - - Expiration Date________ / ________ Billing Zip Code__________________ CID________________ Month Year

Cardholder Signature_____________________________________________________________________________

$_______ TOTAL ENCLOSED** made payable to (ST) Chapter of ASET – The Neurodiagnostic Society [Federal Tax ID###]

**Dues payments and contributions to the (ST) Chapter of ASET General Operations Fund cannot be deducted as charitable contributions for federal income tax purposes. Payments may be partially deducted as an ordinary and necessary business expense. Subscription portion of dues: Institutional members $XX. For the remaining dues, the portion used for lobbying activities is approximately $XX.

The lobbying portion of your dues is not tax deductible.

Section VII: Payment Information

Appendix I-Chapter Bylaws

1

MODEL CHAPTER BYLAWS

ARTICLE I

GENERAL

Section 1. Name. The name of this organization is [__________ Chapter of ASET –

The Neurodiagnostic Society], hereinafter called the “Chapter.”

Section 2. Objectives and Purposes. The objectives and purposes of the Chapter

are to:

A. Promote and provide continuing education in neurodiagnostic

technology;

B. Encourage and assist in the advancement of science and

technical standards of neurodiagnostics

C. Protect and preserve both the patient and public trust in the

neurodiagnostic technologist;

D. Promote increased awareness of neurodiagnostics

E. Function as a professional association with member services that

provide for professional and personal development;

F. Develop and maintain the essentials to perpetuate the chapter

and its objectives.

Section 3. Territory and Location. The chapter will operate and serve members

within the territory of [GEOGRAPHIC DESCRIPTION]. Its Principal Office

will be located in such place as determined by the Chapter’s Board of

Directors.

Section 4. Restrictions. All policies and activities of the Chapter are consistent with:

A. applicable federal, state and local antitrust, trade regulations or

other requirements; and

B. applicable to tax-exemption requirements, including the

requirements that the Chapter not be organized for profit and

that no part of its net earnings insure to the benefit of any private

individual.

No outside commercial interest and no political party nor candidate for

public office shall be endorsed or supported, directly or indirectly, by the

Chapter, nor shall the Chapter name, nor the name of any officer in his or

her official capacity in the Chapter be made available for the benefit or

detriment of any outside commercial interest, political party, or

candidate for public office.

Section 5. Fiscal Year. The fiscal year of the Chapter shall be [DESIGNATE].


2

ARTICLE II

MEMBERSHIP

Section 1. Classification. There shall be [NUMBER] classifications of membership:

[IDENTIFY CLASSES, e.g., Active, Associate, Student, Corporate, and

Honorary].

Section 2. Qualifications and Privileges.

A. [ACTIVE] members shall be individuals whose primary

employment or training is in clinical practice, research, education

or management in neurodiagnostics. [ACTIVE] members who pay

applicable dues established by the Board of Directors shall be

entitled to all membership privileges including the right to vote,

and to hold office and committee appointment.

B. [ASSOCIATE] members shall be individuals who are supportive of

the mission of the Chapter but who do not qualify for membership

under other member categories. [ASSOCIATE] members shall be

entitled to all membership privileges including the right to hold

committee appointment, but shall not be eligible to vote or hold

elected office.

C. [STUDENT] members shall be enrolled full-time in a formal

training program for neurodiagnostics, not including on-the-job

training. Such persons may qualify for student membership for

the length of their educational program. Students shall be

entitled to all membership privileges including the right to hold

committee appointment, but shall not be eligible to vote or hold

elected office.

D. [CORPORATE] members shall be organizations, corporations, or

institutions interested in financially supporting the Chapter.

Corporate members shall be entitled to all membership privileges

including the right to hold committee appointment, but shall not

be eligible to vote or hold elected office.

E. [HONORARY] members shall be individuals who have received

unanimous approval by the Board of Directors in recognition of

their outstanding contribution to the neurodiagnostic profession.

Honorary members shall be excluded from voting, holding elected

office, and serving as committee members.

Section 3. Payment of Dues. Any individual eligible for membership may become a

member upon completion of application and payment of dues as

established by the Board of Directors. Honorary members shall be

exempt from paying dues.

Section 4. Resignation. Any member may resign by submitting a written

resignation. Resignation does not relieve a member from liability for the


3

full annual dues or other obligations accrued and unpaid as of the date of

resignation.

Section 5. Expulsion. A member is automatically expelled without action of the

Board of Directors for failure to pay applicable dues for more than

[NUMBER] days after the date they are owed, or failure to meet the

eligibility requirements for membership, effective the date the member’s

unpaid dues were due. A member may be expelled by the Board of

Directors for other reasons if the member is provided with advance

written notice including the reason for the proposed expulsion, an

opportunity to contest the proposed expulsion in writing or in person

before the Board of Directors, and final written notice of the Board’s

decision.

ARTICLE III

MEMBERSHIP MEETINGS AND VOTING

Section 1. Annual Membership Meetings. An annual membership meeting of the

Chapter shall be held each calendar year, at a time and place determined

by the Board of Directors.

Section 2. Special Meetings. Special meetings of the Chapter shall be called at such

time and place as the Board of Directors may select and shall be called

upon a petition of [NUMBER] members in good standing within thirty

(30) days after receipt by the President of such petition.

Section 3. Notice. Notice of membership meetings is provided to voting members

at least [NUMBER] days before the meetings by postal or other

delivery, facsimile, e-mail, or any other electronic means.

Section 4. Voting. Whenever the members must vote on a matter under these

Bylaws or otherwise, this section will apply. Voting at membership

meetings may be in person [OR BY PROXY] with each voting member

having a single vote. A majority of the members voting in person [OR BY

PROXY] where a quorum is present carries an action. Members may vote

without a meeting in elections or on any matter presented by the Board

of Directors where the votes are submitted in writing by postal or other

delivery, facsimile, e-mail, or any other electronic means and [WHERE A

QUORUM PARTICIPATES. or THE QUESTION SHALL BE DETERMINED

ACCORDING TO THE MAJORITY OF VOTES RECEIVED.]

Section 5. Quorum. Voting members who are present at the annual membership

meeting or any special meeting shall constitute a quorum for the

transition of business. Once a member is present at a meeting, that

member is deemed present for quorum purposes for the remainder of

the meeting.

ARTICLE IV

OFFICERS

Section 1. Officers. Officers of the Chapter shall be a President, [President-Elect or

Vice President], Secretary, Treasurer, [Past-President] and any other


4

Officers as determined by the Board of Directors. The offices of

Secretary and Treasurer may be combined and held by the same person

at the discretion of the Board of Directors. However, the office of

President shall not be held by the same person who holds the office of

Secretary or Treasurer (or both).

Section 2. Duties. The duties of the Officers shall be defined as follows:

A. The President shall be the Chief Executive Officer of the Chapter.

The President shall preside at all meetings of the Chapter and of

the Board of Directors. The President shall appoint the

chairperson of all committees, except the Nominations

Committee, subject to approval of the Board of Directors. The

President shall designate members of the Board of Directors to

act as board liaison for all committees.

B. The [President-elect or Vice President] shall preside at the

meetings of the Chapter and of the Board of Directors in the

absence of the President. In the event of the disability of the

President, the [President-elect or Vice President] shall become

acting President with all the powers of the President. If there

is no [President-elect or Vice President] in office in the event

of the disability of the President, succession shall proceed as

defined in Section 4. The [President-Elect or Vice President]

shall perform such other duties as the President or Board of

Directors may assign.]

C. The Secretary shall keep the records and papers of the

Chapter and shall keep the minutes of all meetings of the

Chapter and of the Board of Directors. The secretary shall

perform such other duties as the President or Board of

Directors may assign.

D. The Treasurer shall collect the annual dues of all members

who are not also members of ASET, and shall keep account for

the Chapter. The Treasurer shall have custody of the funds of

the Chapter, and shall be authorized to open a bank account in

the name of the Chapter. The Treasurer shall be required to

submit an annual accounting and proposed budget, both of

which shall be approved by the Board of Directors and shall be

presented in printed form and available to all members at the

annual meeting. The Treasurer shall secure a fidelity bond at

the expense of the chapter, the limits of which shall be fixed

by the Board of Directors and reviewed as necessary. The

Treasurer shall perform such other duties as the President or

Board of Directors may assign.

E. [The Immediate Past-President shall assume the responsibilities

of Parliamentarian and Archivist. The Immediate Past-President

shall be familiar with Roberts' Rules of Order Newly Revised and

shall assist the President in the orderly conduct of all meetings of

the Chapter. The Immediate Past-President shall interpret all

questions of procedure and Bylaw construction. The Immediate


5

Past-President shall collect and maintain all records, publications,

and papers of historical significance to the Chapter. ]

Section 3. Composition and Election. Officers of the Chapter must be [ACTIVE]

members in good standing of the Chapter. Officers are elected by a

majority of the members voting where a quorum is present. The Board of

Directors sets forth the procedures for how candidates are nominated

and elected and in accordance with Article VI, Section 2.

Section 4. Terms. Officer terms shall be [NUMBER] years in duration, as

determined by the Board of Directors in advance of such terms being

served. Terms of office shall commence with installation as the first

order of business under new business at the annual membership

meeting. Officers shall serve until his or her successor is duly elected

and qualified. The [president-elect or vice president] shall

automatically succeed to the office of president. [The out-going

president becomes the past-president, who shall serve for a period of

one (1) year.] An Officer may not serve more than [NUMBER]

successive terms in the same office.

Section 5. Vacancies. In the event that a vacancy occurs in the office of president,

the [President-elect or Vice President] shall automatically succeed to the

presidency and the office of [president-elect or vice president] shall

remain vacant until the next scheduled balloting for Chapter officers. The

[president-elect or vice president] shall subsequently serve his or her

[NUMBER OF YEARS] term of office as president. In the event that the

President becomes unable to serve in a year when there is no

[President-elect or Vice President] in office, the Board of Directors shall

appoint an interim President, selected from the current Board of

Directors, to serve the remainder of the term. Vacancies among the

other Officers are filled, for the balance of the term of office, by the

Board of Directors. The fulfillment of a vacancy does not constitute a

term.

Section 6. Removal or Resignation. An Officer may be removed by (a) two-thirds of

the members voting where a quorum is present, or (b) three-quarters of

the full Board of Directors, with the Officer proposed to be removed not

voting. If the Officer proposed to be removed is provided with advance

written notice, including the reason for the proposed removal, the Officer

must have an opportunity to contest the proposed removal in writing or

in person, and be given final written notice of the removal decision. An

Officer may resign at any time by providing written notice to the Board of

Directors. Any removal or resignation of a person as an Officer

automatically results in that person’s removal or resignation from the

Board of Directors.

Section 7. Compensation. Officers do not receive compensation for their services

but may be reimbursed for expenses.


6

ARTICLE V

BOARD OF DIRECTORS

Section 1. Directors. The affairs of the Chapter are managed by its Board of

Directors. It is the Board of Directors’ duty to carry out the objectives

and purposes of the Chapter, and to this end the Board of Directors may

exercise all powers of the Chapter. The Board of Directors is subject to

the restrictions and obligations set forth in these Bylaws.

Section 2. Composition and Election. The Board of Directors is composed of the

elected Officers of the Chapter and [NUMBER] additional Directors

elected by the membership. Directors must be [ACTIVE] members in

good standing of the Chapter. Directors are elected by ballot of the

members qualified to vote. The Board of Directors sets forth the

procedures for how candidates are nominated and elected and must be

in accordance with Article VI, Section 2.

Section 3. Terms. Director terms shall be [NUMBER] years in duration. Directors

may serve [NUMBER ] successive terms. Terms of office shall commence

with installation as the first order of business under new business at the

annual membership meeting. For the initial directors, [NUMBER] shall be

elected to serve a [NUMBER] year term, [NUMBER] shall be elected to

serve a [NUMBER] year term, and [NUMBER] shall be elected to serve a

[NUMBER] year term in order to implement thereafter staggered terms

of office.

Section 4. Vacancies. Vacancies among Directors are filled, for the balance of the

term, by a vote of the Board of Directors.

Section 5. Meetings and Voting. Whenever the Directors must vote on a matter

under these Bylaws or otherwise, this section will apply.

(a) Meetings of the Board of Directors are called by the President.

The meeting shall be called by the President or the Secretary on

the written request of [NUMBER] Directors. Meetings may be held

telephonically or electronically as long as each Director can hear

the others.

(b) A majority of Directors forms a quorum; a majority of votes is

required to carry a matter where a quorum is present. Proxy

voting by Directors is not permitted.

(c) Directors may take vote without a meeting on any matter where

all directors eligible to vote participate and the votes are

submitted in writing by postal or other delivery, facsimile, e-mail,

or any other electronic means. An action taken by such a vote is

memorialized by a written consent, which is signed by all

Directors, and describes the action taken and authorized. [Note:

most States will allow voting by written consent only if all

directors vote in favor of the resolution. Please check with

the requirements of the State in which you do business as

to what is allowed when voting without a meeting.]


7

Section 6. Removal. A Director may be removed by (a) two-thirds of the members

voting where a quorum is present, or (b) three-quarters of the full Board

of Directors, with the Director proposed to be removed abstaining from

voting. If the Director proposed to be removed is provided with advance

written notice including the reason for the proposed removal, the

Director must have an opportunity to contest the proposed removal in

writing or in person, and final written notice of the removal decision. A

Director may resign at any time by providing written notice to the Board

of Directors. Any removal or resignation of a person as a Director, where

such person is also an Officer of the Association, automatically results in

that person’s removal or resignation as an Officer.

Section 7. Compensation. Directors do not receive compensation for their services

but may be reimbursed for expenses.

ARTICLE VI

COMMITTEES

Section 1. Executive Committee. There shall be an Executive Committee composed

of the Officers, which shall have all the powers of the Board of Directors

to transact business between Board of Directors meetings in accordance

with rules established by the Board of Directors. Actions required

between Board of Directors meetings shall be ratified at the next

meeting of the Board of Directors.

Section 2. Nominations Committee. Nominations for President [if Vice President

does not automatically succeed to office of president], [President-elect

or Vice President], Secretary, Treasurer, and Directors shall be made by

the Nominations Committee. The Nominations Committee chair shall be

appointed by the Board of Directors and the committee shall consist of

no less than [NUMBER] members. The chair’s term of office is a

[NUMBER] year term staggered between officer elections. Members of

the Nominations Committee must be [MEMBER CLASSIFICATIONS]

members in good standing and are selected by the chair and subject to

the approval of the Board of Directors. The terms of the committee

members shall co-inside with the term of chair.

A. The Nominations Committee shall receive nominations from the

membership and identify [ACTIVE] members who are qualified to

serve and who demonstrate leadership characteristics, as

candidates for vacancies occurring for offices and Board of

Directors.

B. Candidates for office shall have completed at least (NUMBER)

continuous years of membership. Membership status of each

candidate must be current and continuous for the required

number of years measured retrospectively from the nomination

application deadline.

C. The Nominations Committee shall report their selections to the

President no later than sixty (60) days prior to the election.

Names of all nominees shall be published and disseminated to

each voting member no later than thirty (30) days prior to the


8

election. The names of all properly nominated candidates shall

appear on the Official Ballot. Write-in votes shall be permitted.

The candidate receiving the highest number of votes for each

elected position shall be declared to be elected. All elections shall

be held prior to the annual membership meeting except those

elections held to fill vacancies which occur between annual

meetings. Elections may be held by any means permitted by law.

Tie votes shall be broken by the drawing of lots.

Section 3. Other Committees. Committees may be established from time to time

as appropriate and approved by the Board of Directors. Chairpersons

of committees shall be appointed by the President, with approval by

the Board of Directors, and shall be responsible to the Board of

Directors.

A. The chairperson of each committee shall preside at all

committee meetings, shall appoint members to the committee

subject to the approval of the President, and shall render a

report to the membership at each annual meeting of the

Chapter. The Vice-Chairperson appointed by the Chairperson

shall serve as Secretary at each committee meeting.

B. The Board of Directors shall define the function of each

committee. Vacancies occurring in the membership of the

committees shall be filled by appointment by the chairperson of

said committee for the unexpired term, subject to the approval of

the President, except vacancies which occur on the Nominations

Committee, which vacancies shall be filled by the Board of

Directors.

C. The terms of committee appointments shall correspond to the

presidential term, unless a specific term is otherwise approved by

the Board of Directors.

D. The President shall be empowered to appoint task forces,

with approval by the Board of Directors, to supplement

the activities of any committee.

ARTICLE VII

AMENDMENTS

Section 1. These Bylaws may be amended at any annual or special meeting of the

membership, provided that at least thirty (30) days notice of any

proposed amendment is provided to the members in writing by postal

or other delivery, facsimile, e-mail, or any other electronic means.

Section 2. Any amendment to the Bylaws must be approved by two-thirds

(2/3) vote of the members qualified to vote present at the annual

or any special meeting of the membership properly called and

constituted.

Section 3. These Bylaws may be further amended at any annual membership

meeting, properly constituted, upon the unanimous vote of all


9

members duly qualified to vote without the necessity for prior notice

of the proposed amendment.

ARTICLE VIII

PARLIAMENTARY AUTHORITY

The rules contained in Roberts' Rules of Order Newly Revised shall govern all meetings

in all cases in which they are not inconsistent or in conflict with these Bylaws.

ARTICLE IX

CONTRACTS

The Board of Directors may authorize any Director, Officer, agent or employee to enter

into or execute any contract on behalf of the Chapter. However, without such

authorization, no person has the power or authority to bind the Chapter under any

contract or agreement, to pledge the Chapter’s credit, or to render the Chapter liable

for any purpose or amount.

ARTICLE X

CONFLICT OF INTEREST

The Board of Directors shall adopt a conflict-of-interest policy and annual disclosure

process that applies to all Officers and Directors of the Chapter.

ARTICLE XI

INDEMNIFICATION

The Chapter shall indemnify all officers, employees, and agents of the Chapter to the

full extent permitted by the General Laws of [STATE], and shall be entitled to

purchase insurance for such indemnification to the full extent as determined from

time to time by the Executive Committee of the Chapter. Exception is made in such

cases where the indemnified individual is adjudged guilty of willful misfeasance or

malfeasance in the performance of duties. The right of indemnification shall be in

addition to and not exclusive of all other rights to which such indemnified individual

may be entitled.

ARTICLE XII

DISSOLUTION

Upon the dissolution of the Chapter, the Board of Directors, after paying or making

provision for the payment of all of the liabilities of the Chapter, shall dispose of all of the

remaining assets of the Chapter exclusively for the purposes of the Chapter in such

manner, or to such organization or organizations as shall at the time qualify as a

tax-exempt organization or organizations recognized under Section 501(c)(3) of the

Internal Revenue Code of 1986, as amended, or the corresponding provision of any

future United States internal revenue statute, as the Board of Directors shall

determine.

#

Note: The Instructions for Form SS-4 begin on the next page of this document.

Attention

Limit of one (1) Employer Identification Number (EIN) Issuance per Business Day Effective May 21, 2012, to ensure fair and equitable treatment for all taxpayers,

the Internal Revenue Service (IRS) will limit Employer Identification Number

(EIN) issuance to one per responsible party per day. This limitation is applicable

to all requests for EINs whether online or by phone, fax or mail. We apologize for

any inconvenience this may cause.

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Page 1 of 6 Instr. for Form SS-4 (2011) 10:25 - 6-JAN-2011

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Department of the TreasuryInternal Revenue ServiceInstructions for Form SS-4

(Rev. January 2011)Application for Employer Identification Number (EIN)Use with the January 2010 revision of Form SS-4

the number of businesses operated as a sole proprietorship orSection references are to the Internal Revenue Code unlesstrade names under which a business operates. However, if aotherwise noted.sole proprietorship incorporates or enters into a partnership, anew EIN is required. Also, each corporation in an affiliatedgroup must have its own EIN.What’s NewEIN applied for, but not received. If you do not have an EIN

EIN operations contact information. Contact information for by the time a return is due, write ‘‘Applied For’’ and the date youEIN operations at the Philadelphia Internal Revenue Service applied in the space shown for the number. Do not show yourCenter has changed. SSN as an EIN on returns.• The phone number to use for Form SS-4 applicants outside If you do not have an EIN by the time a tax deposit is due,of the United States has changed to 1-267-941-1099. See the send your payment to the Internal Revenue Service Center forNote in the Telephone section under How to Apply, later. your filing area as shown in the instructions for the form that• The ZIP code for EIN Operations at the Philadelphia Internal you are filing. Make your check or money order payable to theRevenue Service Center now includes a ZIP+4 extension. The ‘‘United States Treasury’’ and show your name (as shown onrevised ZIP code is 19255-0525. Form SS-4), address, type of tax, period covered, and date you• The Fax-TIN number for EIN Operations at the Philadelphia applied for an EIN.Internal Revenue Service Center has changed to

Election to file Form 944. Eligible employers may now elect1-267-941-1040. See the Where to File or Fax table on page 2.to file Form 944 annually instead of Forms 941 quarterly. SeeFederal tax deposits must be made by electronic funds Line 14. Do you want to file Form 944? on page 5 for details.transfer. Beginning January 1, 2011, you must use electronicElectronic filing and payment. Businesses can file and payfunds transfer to make all federal tax deposits (such as depositsfederal taxes electronically. Use e-file and the Electronicof employment tax, excise tax, and corporate income tax).Federal Tax Payment System (EFTPS).Forms 8109 and 8109-B, Federal Tax Deposit Coupon, cannot • For additional information about e-file, visit IRS.gov.be used after December 31, 2010. Generally, electronic fund • For additional information about EFTPS, visit www.eftps.govtransfers are made using the Electronic Federal Tax Paymentor call EFTPS Customer Service at 1-800-555-4477,System (EFTPS). If you do not want to use EFTPS, you can1-800-733-4829 (TDD), or 1-800-244-4829 (Spanish).arrange for your tax professional, financial institution, payrollFederal tax deposits. New employers that have a federal taxservice, or other trusted third party to make deposits on yourobligation will be pre-enrolled in EFTPS. EFTPS allows you tobehalf. You also may arrange for your financial institution tomake all of your federal tax payments online at www.eftps.govinitiate a same-day wire on your behalf. EFTPS is a free serviceor by telephone. Shortly after we have assigned you your EIN,provided by the Department of Treasury. Services provided byyou will receive instructions by mail for activating your EFTPSyour tax professional, financial institution, payroll service, orenrollment. You will also receive an EFTPS Personalother third party may have a fee.Identification Number (PIN) that you will use when making yourTo get more information about EFTPS or to enroll in EFTPS,payments, as well as instructions for obtaining an onlinevisit www.eftps.gov or call 1-800-555-4477. Additionalpassword.information about EFTPS is also available in Publication 966,

The Secure Way to Pay Your Federal Taxes. For more information on federal tax deposits, see Pub. 15(Circular E), Employer’s Tax Guide.

General Instructions How To ApplyUse these instructions to complete Form SS-4, Application for

You can apply for an EIN online, by telephone, by fax, or byEmployer Identification Number (EIN). Also see Do I Need anmail, depending on how soon you need to use the EIN. UseEIN? on page 2 of Form SS-4.only one method for each entity so you do not receive morethan one EIN for an entity.Purpose of FormOnline. Taxpayers and authorized third party designeesUse Form SS-4 to apply for an EIN. An EIN is a nine-digitlocated within the United States and U.S. possessions cannumber (for example, 12-3456789) assigned to sole proprietors,receive an EIN online and use it immediately to file a return orcorporations, partnerships, estates, trusts, and other entities formake a payment. Go to the IRS website at www.irs.gov/tax filing and reporting purposes. The information you providebusinesses and click on Employer ID Numbers.on this form will establish your business tax account.

Taxpayers who apply online have an option to view,An EIN is for use in connection with your businessprint, and save their EIN assignment notice at the end ofactivities only. Do not use your EIN in place of yourthe session. (Authorized third party designees will

TIPsocial security number (SSN).CAUTION

!receive the EIN, however, the EIN assignment notice will bemailed to the applicant.)Reminders

Applicants who are not located within the United StatesApply online. Generally, you can apply for and receive an EIN or U.S. possessions cannot use the online application toon IRS.gov. See How To Apply, later. obtain an EIN. Please use one of the other methods toCAUTION!

This is a free service offered by the Internal Revenue apply.Service at IRS.gov. Telephone. You can receive your EIN by telephone and use itTIP

immediately to file a return or make a payment. Call the IRS atFile only one Form SS-4. Generally, a sole proprietor should 1-800-829-4933 (toll free). The hours of operation are 7:00 a.m.file only one Form SS-4 and needs only one EIN, regardless of to 10:00 p.m. local time (Pacific time for Alaska and Hawaii).

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http://www.eftps.gov

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www.eftps.gov

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of 6 Instr. for Form SS-4 (2011) 10:25 - 6-JAN-2011


The person making the call must be authorized to sign the form To order Pub. 1796, IRS Tax Products DVD, callor be an authorized designee. See Third Party Designee and 1-877-233-6767 or go to www.irs.gov/cdorders.Signature on page 6. Also see the first TIP on page 2.

Tax help for your business is available at www.irs.gov/Note. International applicants must call 1-267-941-1099 (not businesses/.toll free).

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If you are applying by telephone, it will be helpful to completeForm SS-4 before contacting the IRS. An IRS representative Related Forms and Publicationswill use the information from the Form SS-4 to establish your

The following forms and instructions may be useful to filers ofaccount and assign you an EIN. Write the number you areForm SS-4.given on the upper right corner of the form and sign and date it. • Form 11-C, Occupational Tax and Registration Return forKeep this copy for your records.Wagering.

If requested by an IRS representative, mail or fax the signed • Form 637, Application for Registration (For Certain ExciseForm SS-4 (including any third party designee authorization) Tax Activities).within 24 hours to the IRS address provided by the IRS • Form 720, Quarterly Federal Excise Tax Return.representative. • Form 730, Monthly Tax Return for Wagers.

• Form 941, Employer’s QUARTERLY Federal Tax Return.Taxpayer representatives can apply for an EIN on behalf• Form 944, Employer’s ANNUAL Federal Tax Return.of their client and request that the EIN be faxed to their• Form 990-T, Exempt Organization Business Income Taxclient on the same day. Note. By using this procedure,

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Return.you are authorizing the IRS to fax the EIN without a cover• Instructions for Form 990-T.sheet.• Form 1023, Application for Recognition of Exemption UnderFax. Under the Fax-TIN program, you can receive your EIN bySection 501(c)(3) of the Internal Revenue Code.fax within 4 business days. Complete and fax Form SS-4 to the • Form 1024, Application for Recognition of Exemption UnderIRS using the appropriate Fax-TIN number listed below. ASection 501(a).long-distance charge to callers outside of the local calling area • Schedule C (Form 1040), Profit or Loss From Business (Solewill apply. Fax-TIN numbers can only be used to apply for anProprietorship).EIN. The numbers may change without notice. Fax-TIN is • Schedule F (Form 1040), Profit or Loss From Farming.available 24 hours a day, 7 days a week. • Instructions for Form 1041 and Schedules A, B, G, J, and

Be sure to provide your fax number so the IRS can fax the K-1, U.S. Income Tax Return for Estates and Trusts.EIN back to you. • Form 1042, Annual Withholding Tax Return for U.S. SourceMail. Complete Form SS-4 at least 4 to 5 weeks before you Income of Foreign Persons.will need an EIN. Sign and date the application and mail it to the • Instructions for Form 1065, U.S. Return of Partnershipservice center address for your state. You will receive your EIN Income.in the mail in approximately 4 weeks. Also see Third Party • Instructions for Form 1066, U.S. Real Estate MortgageDesignee on page 6. Investment Conduit (REMIC) Income Tax Return.

• Instructions for Forms 1120.Call 1-800-829-4933 to verify a number or to ask about the• Form 2290, Heavy Highway Vehicle Use Tax Return.status of an application by mail.• Form 2553, Election by a Small Business Corporation.

Form SS-4 downloaded from IRS.gov is a fill-in form, • Form 2848, Power of Attorney and Declaration ofand when completed, is suitable for faxing or mailing to Representative.the IRS.

TIP• Form 8821, Tax Information Authorization.• Form 8832, Entity Classification Election.• Form 8849, Claim for Refund of Excise Taxes.

Where to File or Fax For more information about filing Form SS-4 and relatedissues, see:

If your principal business, File or fax with the “Internal • Pub. 15 (Circular E), Employer’s Tax Guide;office or agency, or legal Revenue Service Center” • Pub. 51 (Circular A), Agricultural Employer’s Tax Guide;residence in the case of an at: • Pub. 538, Accounting Periods and Methods;individual, is located in: • Pub. 542, Corporations;

• Pub. 557, Tax-Exempt Status for Your Organization;Attn: EIN Operation • Pub. 583, Starting a Business and Keeping Records;

One of the 50 states or the Cincinnati, OH 45999 • Pub. 966, The Secure Way to Pay Your Federal Taxes forDistrict of Columbia Business and Individual Taxpayers;

Fax-TIN: 859-669-5760 • Pub. 1635, Understanding Your EIN.

If you have no legal Attn: EIN Operationresidence, principal place of Philadelphia, PAbusiness, or principal office 19255-0525 Specific Instructionsor agency in any state or the

Follow the instructions for each line to expedite processing andDistrict of Columbia: Fax-TIN: 267-941-1040 to avoid unnecessary IRS requests for additional information.Enter “N/A” on the lines that do not apply.

Line 1. Legal name of entity (or individual) for whom theHow To Get Forms and PublicationsEIN is being requested. Enter the legal name of the entity (or

Internet. You can download, view, and order tax forms, individual) applying for the EIN exactly as it appears on theinstructions, and publications at IRS.gov. social security card, charter, or other applicable legal document.Phone. Call 1-800-TAX-FORM (1-800-829-3676) to order An entry is required.forms, instructions, and publications. You should receive your

Individuals. Enter your first name, middle initial, and lastorder or notification of its status within 10 workdays.name. If you are a sole proprietor, enter your individual name,DVD for Tax Products. For small businesses, return not your business name. Enter your business name on line 2.preparers, or others who may frequently need tax forms or Do not use abbreviations or nicknames on line 1.publications, a DVD containing over 2,000 tax products

(including many prior year forms) can be purchased from the Trusts. Enter the name of the trust as it appears on theNational Technical Information Service (NTIS). trust instrument.

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http://www.irs.gov/cdorders

www.irs.gov/businesses/

www.irs.gov/businesses/



Estate of a decedent. Enter the name of the estate. For an necessary, complete Form W-7, Application for IRS Individualestate that has no legal name, enter the name of the decedent Taxpayer Identification Number, to obtain an ITIN.followed by “Estate.” You must enter an SSN, ITIN, or EIN on line 7b unless the

Partnerships. Enter the legal name of the partnership as it only reason you are applying for an EIN is to make an entityappears in the partnership agreement. classification election (see Regulations sections 301.7701-1

through 301.7701-3) and you are a nonresident alien or otherCorporations. Enter the corporate name as it appears inforeign entity with no effectively connected income fromthe corporate charter or other legal document creating it.sources within the United States.Plan administrators. Enter the name of the planLines 8a–c. Limited liability company (LLC) information.administrator. A plan administrator who already has an EINAn LLC is an entity organized under the laws of a state orshould use that number.foreign country as a limited liability company. For federal taxLine 2. Trade name of business. Enter the trade name of thepurposes, an LLC may be treated as a partnership orbusiness if different from the legal name. The trade name is thecorporation or be disregarded as an entity separate from its‘‘doing business as’’ (DBA) name.owner.

Use the full legal name shown on line 1 on all tax By default, a domestic LLC with only one member isreturns filed for the entity. (However, if you enter a trade disregarded as an entity separate from its owner and mustname on line 2 and choose to use the trade nameCAUTION

!include all of its income and expenses on the owner’s tax return

instead of the legal name, enter the trade name on all returns (for example, Schedule C (Form 1040)). Also by default, ayou file.) To prevent processing delays and errors, use only the domestic LLC with two or more members is treated as alegal name (or the trade name) on all tax returns. partnership. A domestic LLC may file Form 8832 to avoid eitherLine 3. Executor, administrator, trustee, ‘‘care of’’ name. default classification and elect to be classified as an associationFor trusts, enter the name of the trustee. For estates, enter the taxable as a corporation. For more information on entityname of the executor, administrator, or other fiduciary. If the classifications (including the rules for foreign entities), see theentity applying has a designated person to receive tax instructions for Form 8832.information, enter that person’s name as the ‘‘care of’’ person. If the answer to line 8a is “Yes,” enter the number of LLCEnter the individual’s first name, middle initial, and last name. members. If the LLC is owned solely by a husband and wife in aLines 4a–b. Mailing address. Enter the mailing address for community property state and the husband and wife choose tothe entity’s correspondence. If the entity’s address is outside treat the entity as a disregarded entity, enter “1” on line 8b.the United States or its possessions, you must enter the city,

Do not file Form 8832 if the LLC accepts the defaultprovince or state, postal code, and the name of the country. Doclassifications above. If the LLC is eligible to be treatednot abbreviate the country name. If line 3 is completed, enteras a corporation that meets certain tests and it will beCAUTION

!the address for the executor, trustee or “care of” person.

electing S corporation status, it must timely file Form 2553. TheGenerally, this address will be used on all tax returns.LLC will be treated as a corporation as of the effective date of If the entity is filing the Form SS-4 only to obtain an EIN for the S corporation election and does not need to file Form 8832.the Form 8832, use the same address where you would like to See the Instructions for Form 2553.have the acceptance or nonacceptance letter sent.Line 9a. Type of entity. Check the box that best describes the

File Form 8822, Change of Address, to report any type of entity applying for the EIN. If you are an alien individualsubsequent changes to the entity’s mailing address. with an ITIN previously assigned to you, enter the ITIN in placeTIP

of a requested SSN.Lines 5a–b. Street address. Provide the entity’s physical This is not an election for a tax classification of an entity.address only if different from its mailing address shown in lines See Disregarded entities on page 4.4a–b. Do not enter a P.O. box number here. If the entity’s CAUTION

!address is outside the United States or its possessions, you

Sole proprietor. Check this box if you file Schedule C, ormust enter the city, province or state, postal code, and theSchedule F (Form 1040) and have a qualified plan, or arename of the country. Do not abbreviate the country name.required to file excise, employment, alcohol, tobacco, orLine 6. County and state where principal business isfirearms returns, or are a payer of gambling winnings. Enterlocated. Enter the entity’s primary physical location.your SSN (or ITIN) in the space provided. If you are a

Lines 7a–b. Name of responsible party. Enter the full name nonresident alien with no effectively connected income from(first name, middle initial, last name, if applicable) and SSN, sources within the United States, you do not need to enter anITIN (individual taxpayer identification number), or EIN of the SSN or ITIN.entity’s responsible party as defined below.

Corporation. This box is for any corporation other than aResponsible party defined. For entities with shares or personal service corporation. If you check this box, enter the

interests traded on a public exchange, or which are registered income tax form number to be filed by the entity in the spacewith the Securities and Exchange Commission, “responsible provided.party” is (a) the principal officer, if the business is a corporation,

If you entered “1120S” after the “Corporation” checkbox,(b) a general partner, if a partnership, (c) the owner of an entitythe corporation must file Form 2553 no later than thethat is disregarded as separate from its owner (disregarded15th day of the 3rd month of the tax year the election isentities owned by a corporation enter the corporation’s name CAUTION

!to take effect. Until Form 2553 has been received andand EIN), or (d) a grantor, owner, or trustor, if a trust.approved, you will be considered a Form 1120 filer. See theFor all other entities, “responsible party” is the person whoInstructions for Form 2553.has a level of control over, or entitlement to, the funds or assets

Personal service corporation. Check this box if the entityin the entity that, as a practical matter, enables the individual,is a personal service corporation. An entity is a personal servicedirectly or indirectly, to control, manage, or direct the entity andcorporation for a tax year only if:the disposition of its funds and assets. The ability to fund the• The principal activity of the entity during the testing periodentity or the entitlement to the property of the entity alone,(prior tax year) for the tax year is the performance of personalhowever, without any corresponding authority to control,services substantially by employee-owners, andmanage, or direct the entity (such as in the case of a minor• The employee-owners own at least 10% of the fair marketchild beneficiary), does not cause the individual to be avalue of the outstanding stock in the entity on the last day of theresponsible party.testing period.If the person in question is an alien individual with a

previously assigned ITIN, enter the ITIN in the space provided Personal services include performance of services in suchand submit a copy of an official identifying document. If fields as health, law, accounting, or consulting. For more

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information about personal service corporations, see the For wages paid on or after January 1, 2009, the disregardedInstructions for Form 1120 and Pub. 542. entity is required to use its name and EIN for reporting and

payment of employment taxes. A disregarded entity is alsoIf the corporation is recently formed, the testing period required to use its name and EIN to register for excise taxbegins on the first day of its tax year and ends on the activities on Form 637, pay and report excise taxes reported onearlier of the last day of its tax year, or the last day ofCAUTION

!Forms 720, 730, 2290, and 11-C, and claim any refunds,

the calendar year in which its tax year begins. credits, and payments on Form 8849. See the instructions forOther nonprofit organization. Check this box if the the employment and excise tax returns for more information.

nonprofit organization is other than a church or Complete Form SS-4 for disregarded entities as follows.church-controlled organization and specify the type of nonprofit • If a disregarded entity is filing Form SS-4 to obtain an EINorganization (for example, an educational organization). because it is required to report and pay employment and excise

taxes (see above) or for non-federal purposes such as a stateIf the organization also seeks tax-exempt status, yourequirement, check the “Other” box for line 9a and writemust file either Form 1023 or Form 1024. See Pub. 557“disregarded entity” (or “disregarded entity-sole proprietorship”for more information.CAUTION

!if the owner of the disregarded entity is an individual).

If the organization is covered by a group exemption letter, • If the disregarded entity is requesting an EIN for purposes ofenter the four-digit group exemption number (GEN) in the last filing Form 8832 to elect classification as an association taxableentry. (Do not confuse the GEN with the nine-digit EIN.) If you as a corporation, or Form 2553 to elect S corporation status,do not know the GEN, contact the parent organization. See check the “Corporation” box for line 9a and writePub. 557 for more information about group exemption letters. “single-member” and the form number of the return that will be

filed (Form 1120 or 1120S).If the organization is a section 527 political organization,• If the disregarded entity is requesting an EIN because it hascheck the box for Other nonprofit organization and specifyacquired one or more additional owners and its classification“section 527 organization” in the space to the right. To behas changed to partnership under the default rules ofrecognized as exempt from tax, a section 527 politicalRegulations section 301.7701-3(f), check the “Partnership” boxorganization must electronically file Form 8871, Politicalfor line 9a.Organization Notice of Section 527 Status, within 24 hours of

the date on which the organization was established. The Line 10. Reason for applying. Check only one box. Do notorganization may also have to file Form 8872, Political enter “N/A.” A selection is required.Organization Report of Contributions and Expenditures. See Started new business. Check this box if you are starting awww.irs.gov/polorgs for more information. new business that requires an EIN. If you check this box, enter

the type of business being started. Do not apply if you alreadyPlan administrator. If the plan administrator is anhave an EIN and are only adding another place of business.individual, enter the plan administrator’s taxpayer identification

number (TIN) in the space provided. Hired employees. Check this box if the existing business isrequesting an EIN because it has hired or is hiring employeesREMIC. Check this box if the entity has elected to beand is therefore required to file employment tax returns. Do nottreated as a real estate mortgage investment conduit (REMIC).apply if you already have an EIN and are only hiring employees.See the Instructions for Form 1066 for more information.For information on employment taxes (for example, for familyState/local government. If you are a government employer members), see Pub. 15 (Circular E).and you are not sure of your social security and Medicare

coverage options, go to www.ncsssa.org/statessadminmenu. You must make electronic deposits of all depositoryhtml to obtain the contact information for your state’s Social taxes (such as employment tax, excise tax, andSecurity Administrator. corporate income tax) using EFTPS. See Federal taxCAUTION

!deposits must be made by electronic funds transfer on page 1;Other. If not specifically listed, check the ‘‘Other’’ box, entersection 11, Depositing Taxes, in Pub. 15 (Circular E); and Pub.the type of entity and the type of return, if any, that will be filed966.(for example, “Common Trust Fund, Form 1065” or “Created a

Banking purpose. Check this box if you are requesting anPension Plan”). Do not enter “N/A.” If you are an alien individualEIN for banking purposes only, and enter the banking purposeapplying for an EIN, see the Lines 7a–b instructions on page 3.(for example, a bowling league for depositing dues or an• Household employer. If you are an individual that willinvestment club for dividend and interest reporting).employ someone to provide services in your household, check

the ‘‘Other’’ box and enter ‘‘Household Employer’’ and your Changed type of organization. Check this box if theSSN. If you are a trust that qualifies as a household employer, business is changing its type of organization. For example, theyou do not need a separate EIN for reporting tax information business was a sole proprietorship and has been incorporatedrelating to household employees; use the EIN of the trust. or has become a partnership. If you check this box, specify in• Household employer agent. If you are an agent of a the space provided (including available space immediatelyhousehold employer that is a disabled individual or other below) the type of change made. For example, ‘‘From Solewelfare recipient receiving home care services through a state Proprietorship to Partnership.’’or local program, check the “Other” box and enter “Household Purchased going business. Check this box if youEmployer Agent.” (See Rev. Proc. 80-4, 1980-1 C.B. 581; Rev. purchased an existing business. Do not use the former owner’sProc. 84-33, 1984-1 C.B. 502; and Notice 2003-70, 2003-43 EIN unless you became the “owner” of a corporation byI.R.B. 916.) If you are a state or local government also check acquiring its stock.the box for state/local government. Created a trust. Check this box if you created a trust, and• QSub. For a qualified subchapter S subsidiary (QSub) check enter the type of trust created. For example, indicate if the trustthe ‘‘Other’’ box and specify ‘‘QSub.’’ is a nonexempt charitable trust or a split-interest trust.• Withholding agent. If you are a withholding agent required

Exception. Do not file this form for certain grantor-typeto file Form 1042, check the ‘‘Other’’ box and entertrusts. The trustee does not need an EIN for the trust if the‘‘Withholding Agent.’’trustee furnishes the name and TIN of the grantor/owner and

Disregarded entities. A disregarded entity is an eligible the address of the trust to all payers. However, grantor trustsentity that is disregarded as separate from its owner for federal that do not file using Optional Method 1 and IRA trusts that areincome tax purposes. Disregarded entities include required to file Form 990-T, Exempt Organization Businesssingle-member limited liability companies (LLCs) that are Income Tax Return, must have an EIN. For more information ondisregarded as separate from their owners, qualified subchapter grantor trusts, see the Instructions for Form 1041.S subsidiaries (qualified subsidiaries of an S corporation), and

Do not check this box if you are applying for a trust EINcertain qualified foreign entities. See the Instructions for Formwhen a new pension plan is established. Check8832 and Regulations section 301.7701-3 for more information‘‘Created a pension plan.’’on domestic and foreign disregarded entities.

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http://www.irs.gov/charities/political/index.html

http://www.ncsssa.org/statessadminmenu.html

http://www.ncsssa.org/statessadminmenu.html



Created a pension plan. Check this box if you have For employers in the U.S. possessions, generally, if youcreated a pension plan and need an EIN for reporting purposes. pay $6,536 or less in wages subject to social securityAlso, enter the type of plan in the space provided. and Medicare taxes, you are likely to pay $1,000 or less

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in employment taxes.Check this box if you are applying for a trust EIN when a For more information on employment taxes, see Pub. 15new pension plan is established. In addition, check the (Circular E); or Pub. 51 (Circular A) if you have agricultural“Other” box on line 9a and write “Created a Pension

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employees (farmworkers).Plan” in the space provided.Line 15. First date wages or annuities were paid. If the

Other. Check this box if you are requesting an EIN for any business has employees, enter the date on which the businessother reason; and enter the reason. For example, a began to pay wages or annuities. For foreign applicants, this isnewly-formed state government entity should enter the date you began to pay wages in the United States. If the“Newly-Formed State Government Entity” in the space business does not plan to have employees, enter “N/A.”provided.

Withholding agent. Enter the date you began or will beginLine 11. Date business started or acquired. If you are to pay income (including annuities) to a nonresident alien. Thisstarting a new business, enter the starting date of the business. also applies to individuals who are required to file Form 1042 toIf the business you acquired is already operating, enter the date report alimony paid to a nonresident alien. For foreignyou acquired the business. For foreign applicants, this is the applicants, this is the date you began or will begin to paydate you began or acquired a business in the United States. If income (including annuities) to a nonresident alien in the Unitedyou are changing the form of ownership of your business, enter States.the date the new ownership entity began. Trusts should enter Line 16. Check the one box on line 16 that best describes thethe date the trust was funded. Estates should enter the date of principal activity of the applicant’s business. Check the “Other”death of the decedent whose name appears on line 1 or the box (and specify the applicant’s principal activity) if none of thedate when the estate was legally funded. listed boxes applies. You must check a box.Line 12. Closing month of accounting year. Enter the last Construction. Check this box if the applicant is engaged inmonth of your accounting year or tax year. An accounting or tax erecting buildings or engineering projects (for example, streets,year is usually 12 consecutive months, either a calendar year or highways, bridges, tunnels). The term “Construction” alsoa fiscal year (including a period of 52 or 53 weeks). A calendar includes special trade contractors (for example, plumbing,year is 12 consecutive months ending on December 31. A fiscal HVAC, electrical, carpentry, concrete, excavation, etc.year is either 12 consecutive months ending on the last day of contractors).any month other than December or a 52-53 week year. For Real estate. Check this box if the applicant is engaged inmore information on accounting periods, see Pub. 538. renting or leasing real estate to others; managing, selling,

Individuals. Your tax year generally will be a calendar buying, or renting real estate for others; or providing related realyear. estate services (for example, appraisal services). Also check

this box for mortgage real estate investment trusts (REITs).Partnerships. Partnerships must adopt one of the following Mortgage REITs are engaged in issuing shares of fundstax years. consisting primarily of portfolios of real estate mortgage assets• The tax year of the majority of its partners. with gross income of the trust solely derived from interest• The tax year common to all of its principal partners. earned.• The tax year that results in the least aggregate deferral ofRental and leasing. Check this box if the applicant isincome.

engaged in providing tangible goods such as autos, computers,• In certain cases, some other tax year.consumer goods, or industrial machinery and equipment to

See the Instructions for Form 1065 for more information. customers in return for a periodic rental or lease payment. Alsocheck this box for equity real estate investment trusts (REITs).REMICs. REMICs must have a calendar year as their taxEquity REITs are engaged in issuing shares of funds consistingyear.primarily of portfolios of real estate assets with gross income of

Personal service corporations. A personal service the trust derived from renting real property.corporation generally must adopt a calendar year unless it Manufacturing. Check this box if the applicant is engagedmeets one of the following requirements. in the mechanical, physical, or chemical transformation of• It can establish a business purpose for having a different tax materials, substances, or components into new products. Theyear. assembling of component parts of manufactured products is• It elects under section 444 to have a tax year other than a also considered to be manufacturing.calendar year.

Transportation & warehousing. Check this box if theTrusts. Generally, a trust must adopt a calendar year applicant provides transportation of passengers or cargo;

except for the following trusts. warehousing or storage of goods; scenic or sight-seeing• Tax-exempt trusts. transportation; or support activities related to transportation.• Charitable trusts.Finance & insurance. Check this box if the applicant is• Grantor-owned trusts.

engaged in transactions involving the creation, liquidation, orLine 13. Highest number of employees expected in the next change of ownership of financial assets and/or facilitating such12 months. Complete each box by entering the number financial transactions; underwriting annuities/insurance policies;(including zero (“-0-”)) of “Agricultural,” “Household,” or “Other” facilitating such underwriting by selling insurance policies; or byemployees expected by the applicant in the next 12 months. providing other insurance or employee-benefit related services.

Health care & social assistance. Check this box if theIf no employees are expected, skip line 14.applicant is engaged in providing physical, medical, or

Line 14. Do you want to file Form 944? If you expect your psychiatric care or providing social assistance activities such asemployment tax liability to be $1,000 or less in a full calendar youth centers, adoption agencies, individual/family services,year, you are eligible to file Form 944 annually (once each year) temporary shelters, daycare, etc.instead of filing Form 941 quarterly (every three months). Your

Accommodation & food services. Check this box if theemployment tax liability generally will be $1,000 or less if youapplicant is engaged in providing customers with lodging, mealexpect to pay $4,000 or less in total wages subject to socialpreparation, snacks, or beverages for immediate consumption.security and Medicare taxes and federal income tax

withholding. If you qualify and want to file Form 944 instead of Wholesale–agent/broker. Check this box if the applicantForms 941, check the box on line 14. If you do not check the is engaged in arranging for the purchase or sale of goodsbox, then you must file Form 941 for every quarter. owned by others or purchasing goods on a commission basis

-5-Instr. for Form SS-4 (2011)



for goods traded in the wholesale market, usually between Internal Revenue Service. If your entity is required to obtain anbusinesses. EIN, you are required to provide all of the information requested

on this form. Information on this form may be used to determineWholesale–other. Check this box if the applicant iswhich federal tax returns you are required to file and to provideengaged in selling goods in the wholesale market generally toyou with related forms and publications.other businesses for resale on their own account, goods used in

production, or capital or durable nonconsumer goods. We disclose this form to the Social Security Administration(SSA) for their use in determining compliance with applicableRetail. Check this box if the applicant is engaged in sellinglaws. We may give this information to the Department of Justicemerchandise to the general public from a fixed store; by direct,for use in civil and/or criminal litigation, and to cities, states, themail-order, or electronic sales; or by using vending machines.District of Columbia, and U.S. commonwealths andOther. Check this box if the applicant is engaged in anpossessions for use in administering their tax laws. We mayactivity not described above. Describe the applicant’s principalalso disclose this information to other countries under a taxbusiness activity in the space provided.treaty, to federal and state agencies to enforce federal nontaxLine 17. Use line 17 to describe the applicant’s principal line of criminal laws, and to federal law enforcement and intelligencebusiness in more detail. For example, if you checked the agencies to combat terrorism.“Construction” box on line 16, enter additional detail such as

We will be unable to issue an EIN to you unless you provide“General contractor for residential buildings” on line 17. Anall of the requested information that applies to your entity.entry is required. For mortgage REITs indicate mortgage REITProviding false information could subject you to penalties.and for equity REITs indicate what type of real property is the

You are not required to provide the information requested onprincipal type (residential REIT, nonresidential REIT,a form that is subject to the Paperwork Reduction Act unlessminiwarehouse REIT).the form displays a valid OMB control number. Books orLine 18. Check the applicable box to indicate whether or notrecords relating to a form or its instructions must be retained asthe applicant entity applying for an EIN was issued onelong as their contents may become material in thepreviously.administration of any Internal Revenue law. Generally, taxThird Party Designee. Complete this section only if you want returns and return information are confidential, as required byto authorize the named individual to receive the entity’s EIN and section 6103.answer questions about the completion of Form SS-4. The

The time needed to complete and file this form will varydesignee’s authority terminates at the time the EIN is assigneddepending on individual circumstances. The estimated averageand released to the designee. You must complete the signaturetime is:area for the authorization to be valid.

Signature. When required, the application must be signed by Recordkeeping . . . . . . . . . . . . . . . . . . . . . . . 8 hrs., 36 min.(a) the individual, if the applicant is an individual, (b) thepresident, vice president, or other principal officer, if the Learning about the law or the form . . . . . . . . . 42 min.applicant is a corporation, (c) a responsible and duly authorizedmember or officer having knowledge of its affairs, if the Preparing, copying, assembling, and sendingapplicant is a partnership, government entity, or other the form to the IRS . . . . . . . . . . . . . . . . . . . . . 52 min.unincorporated organization, or (d) the fiduciary, if the applicant

If you have comments concerning the accuracy of these timeis a trust or an estate. Foreign applicants may have anyestimates or suggestions for making this form simpler, weduly-authorized person (for example, division manager) signwould be happy to hear from you. You can write to InternalForm SS-4.Revenue Service, Tax Products Coordinating Committee,

Privacy Act and Paperwork Reduction Act Notice. We ask SE:W:CAR:MP:T:T:SP, IR-6526, 1111 Constitution Avenue,for the information on this form to carry out the Internal NW, Washington, DC 20224. Do not send the form to thisRevenue laws of the United States. We need it to comply with address. Instead, see Where to File or Fax on page 2.section 6109 and the regulations thereunder, which generallyrequire the inclusion of an employer identification number (EIN)on certain returns, statements, or other documents filed with the


Note: Form SS-4 begins on the next page of this document.

Attention

Limit of one (1) Employer Identification Number (EIN) Issuance per Business Day Effective May 21, 2012, to ensure fair and equitable treatment for all taxpayers,

the Internal Revenue Service (IRS) will limit Employer Identification Number

(EIN) issuance to one per responsible party per day. This limitation is applicable

to all requests for EINs whether online or by phone, fax or mail. We apologize for

any inconvenience this may cause.

Application for Employer Identification Number Form SS-4 EIN

(Rev. January 2010) (For use by employers, corporations, partnerships, trusts, estates, churches,government agencies, Indian tribal entities, certain individuals, and others.)

OMB No. 1545-0003

Department of the TreasuryInternal Revenue Service

Legal name of entity (or individual) for whom the EIN is being requested

1

Executor, administrator, trustee, “care of” name

3

Trade name of business (if different from name on line 1)

2

Mailing address (room, apt., suite no. and street, or P.O. box)

4a

Street address (if different) (Do not enter a P.O. box.)

5a

City, state, and ZIP code (if foreign, see instructions)

4b

City, state, and ZIP code (if foreign, see instructions)

5b

County and state where principal business is located

6

Name of responsible party

7a

Estate (SSN of decedent)

Type of entity (check only one box). Caution. If 8a is “Yes,” see the instructions for the correct box to check.

9a

Partnership

Plan administrator (TIN)

Sole proprietor (SSN)

Farmers’ cooperative

Corporation (enter form number to be filed) ©

Personal service corporation

REMIC

Church or church-controlled organization

National Guard

Trust (TIN of grantor)

Group Exemption Number (GEN) if any ©

Other nonprofit organization (specify) ©

Other (specify) ©

9b

If a corporation, name the state or foreign country(if applicable) where incorporated

Changed type of organization (specify new type) ©

Reason for applying (check only one box)

10

Purchased going business

Started new business (specify type) ©

Hired employees (Check the box and see line 13.)

Created a trust (specify type) ©

Created a pension plan (specify type) ©

Banking purpose (specify purpose) ©

Other (specify) ©

12

11

Closing month of accounting year

Date business started or acquired (month, day, year). See instructions.

15 First date wages or annuities were paid (month, day, year). Note. If applicant is a withholding agent, enter date income will first be paid tononresident alien (month, day, year) ©

Household

Agricultural

13 Highest number of employees expected in the next 12 months (enter -0- if none).

17 Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.

18 Has the applicant entity shown on line 1 ever applied for and received an EIN? Yes No

Complete this section only if you want to authorize the named individual to receive the entity’s EIN and answer questions about the completion of this form.

Designee’s telephone number (include area code)

Date ©

Signature ©

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Form SS-4 (Rev. 1-2010)

Typ

e o

r p

rint

cle

arly

.

Cat. No. 16055N

Foreign country

State

Designee’s fax number (include area code)

© See separate instructions for each line.

( )

( )

© Keep a copy for your records.

Compliance with IRS withholding regulations

SSN, ITIN, or EIN

7b

Other

Applicant’s telephone number (include area code)

Applicant’s fax number (include area code)

( )

( )

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.

Name and title (type or print clearly) ©

ThirdPartyDesignee

Designee’s name

Address and ZIP code

Federal government/military Indian tribal governments/enterprises

State/local government

If you expect your employment tax liability to be $1,000or less in a full calendar year and want to file Form 944annually instead of Forms 941 quarterly, check here.(Your employment tax liability generally will be $1,000or less if you expect to pay $4,000 or less in totalwages.) If you do not check this box, you must fileForm 941 for every quarter.

Is this application for a limited liability company (LLC) (or a foreign equivalent)?

No

Yes

8a

If 8a is “Yes,” enter the number ofLLC members ©

8b

If 8a is “Yes,” was the LLC organized in the United States?

8c

No

Yes

14

Check one box that best describes the principal activity of your business.

16 Construction Real estate

Rental & leasing Manufacturing

Transportation & warehousing Finance & insurance

Health care & social assistance Accommodation & food service Other (specify)

Wholesale-agent/broker Wholesale-other

Retail

If “Yes,” write previous EIN here ©

If no employees expected, skip line 14.

Do I Need an EIN?File Form SS-4 if the applicant entity does not already have an EIN but is required to show an EIN on any return, statement,or other document.1 See also the separate instructions for each line on Form SS-4.

IF the applicant... AND... THEN...

Started a new business

Hired (or will hire) employees,including household employees

Opened a bank account

Changed type of organization

Purchased a going business 3

Created a trust

Created a pension plan as aplan administrator 5

Is a foreign person needing anEIN to comply with IRSwithholding regulations

Is administering an estate

Is a withholding agent fortaxes on non-wage incomepaid to an alien (i.e.,individual, corporation, orpartnership, etc.)Is a state or local agency

Is a single-member LLC

Is an S corporation

Does not currently have (nor expect to have)employees

Does not already have an EIN

Needs an EIN for banking purposes only

Either the legal character of the organization or itsownership changed (for example, you incorporate asole proprietorship or form a partnership) 2

Does not already have an EIN

The trust is other than a grantor trust or an IRAtrust 4

Needs an EIN for reporting purposes

Needs an EIN to complete a Form W-8 (other thanForm W-8ECI), avoid withholding on portfolio assets,or claim tax treaty benefits 6

Needs an EIN to report estate income on Form 1041

Is an agent, broker, fiduciary, manager, tenant, orspouse who is required to file Form 1042, AnnualWithholding Tax Return for U.S. Source Income ofForeign Persons

Serves as a tax reporting agent for public assistancerecipients under Rev. Proc. 80-4, 1980-1 C.B. 581 7

Needs an EIN to file Form 8832, ClassificationElection, for filing employment tax returns andexcise tax returns, or for state reporting purposes 8

Needs an EIN to file Form 2553, Election by a SmallBusiness Corporation 9

Complete lines 1, 2, 4a–8a, 8b–c (if applicable), 9a,9b (if applicable), and 10–14 and 16–18.

Complete lines 1, 2, 4a–6, 7a–b (if applicable), 8a,8b–c (if applicable), 9a, 9b (if applicable), 10–18.

Complete lines 1–5b, 7a–b (if applicable), 8a, 8b–c(if applicable), 9a, 9b (if applicable), 10, and 18.

Complete lines 1–18 (as applicable).


Complete lines 1–6, 9a, 10–12, 13–17 (if applicable),and 18.

Complete lines 1–5b, 7a–b (SSN or ITIN optional),8a, 8b–c (if applicable), 9a, 9b (if applicable), 10,and 18.

Complete lines 1, 3, 4a–5b, 9a, 10, and 18.

Complete lines 1, 2, 3 (if applicable), 4a–5b, 7a–b (ifapplicable), 8a, 8b–c (if applicable), 9a, 9b (ifapplicable), 10, and 18.

Complete lines 1, 2, 4a–5b, 9a, 10, and 18.



3 Do not use the EIN of the prior business unless you became the “owner” of a corporation by acquiring its stock.4 However, grantor trusts that do not file using Optional Method 1 and IRA trusts that are required to file Form 990-T, Exempt Organization Business Income Tax

Return, must have an EIN. For more information on grantor trusts, see the Instructions for Form 1041.5 A plan administrator is the person or group of persons specified as the administrator by the instrument under which the plan is operated.6 Entities applying to be a Qualified Intermediary (QI) need a QI-EIN even if they already have an EIN. See Rev. Proc. 2000-12.7 See also Household employer on page 4 of the instructions. Note. State or local agencies may need an EIN for other reasons, for example, hired employees.8 See Disregarded entities on page 4 of the instructions for details on completing Form SS-4 for an LLC.9 An existing corporation that is electing or revoking S corporation status should use its previously-assigned EIN.


Form SS-4 (Rev. 1-2010) Page 2

1 For example, a sole proprietorship or self-employed farmer who establishes a qualified retirement plan, or is required to file excise, employment, alcohol,tobacco, or firearms returns, must have an EIN. A partnership, corporation, REMIC (real estate mortgage investment conduit), nonprofit organization(church, club, etc.), or farmers’ cooperative must use an EIN for any tax-related purpose even if the entity does not have employees.

2 However, do not apply for a new EIN if the existing entity only (a) changed its business name, (b) elected on Form 8832 to change the way it is taxed (or iscovered by the default rules), or (c) terminated its partnership status because at least 50% of the total interests in partnership capital and profits were sold orexchanged within a 12-month period. The EIN of the terminated partnership should continue to be used. See Regulations section 301.6109-1(d)(2)(iii).

Appendix L-Chapter Balance Template

ASSETS

Current Assets

(Bank Name) Checking 0.00$

Petty Cash 0.00

Accounts Receivables 0.00

Prepaid Expenses 0.00

Total Current Assets 0.00

Property and Equipment

Equipment 0.00

Accumulated Depreciation 0.00

Total Property and Equipment 0.00

Other Assets

Security Deposit 0.00

Total Other Assets 0.00

Total Assets 0.00$

LIABILITIES AND CAPITAL

Current Liabilities

Accounts Payable 0.00

Total Current Liabilities 0.00

Capital

Retained Earnings 0.00

Net Income 0.00

Total Capital 0.00

Total Liabilities & Capital 0.00$

(ST) Chapter of ASET-The Neurodiagnostic Society

Model Balance Sheet

December 31, 20##

12/3/2012 at 1:10 PM Unaudited - For Management Purposes Only

Appendix L-Chapter Balance Template


Model Balance Sheet

December 31, 20##

12/3/2012 at 1:10 PM Unaudited - For Management Purposes Only

Appendix-M Income and Expense Statement Template

Current Month Year to Date

Revenues

Interest Income 0.00 0.00 0.00 0.00

Misc. Income 0.00 0.00 0.00 0.00

Dues -- Active 0.00 0.00 0.00 0.00

Dues -- Associate 0.00 0.00 0.00 0.00

Dues -- Institutional 0.00 0.00 0.00 0.00

Dues -- Student 0.00 0.00 0.00 0.00

Dues-Corporate 0.00 0.00 0.00 0.00

Advertising 0.00 0.00 0.00 0.00

Registrations-Conference 0.00 0.00 0.00 0.00

Registrations-Seminar 0.00 0.00 0.00 0.00

Exhibits 0.00 0.00 0.00 0.00

Conference Sponsorships 0.00 0.00 0.00 0.00

Off Site Ticket Sales 0.00 0.00 0.00 0.00

Web site-Advertising 0.00 0.00 0.00 0.00

Total Revenues 0.00 0.00 0.00 0.00

Expense

Accounting Fees 0.00 0.00 0.00 0.00

Bad Debt Expense 0.00 0.00 0.00 0.00

Bank Fees 0.00 0.00 0.00 0.00

Credit Card Fees 0.00 0.00 0.00 0.00

Dues & Subscriptions 0.00 0.00 0.00 0.00

Insurance 0.00 0.00 0.00 0.00

Legal Fees 0.00 0.00 0.00 0.00

Other Professional Fees 0.00 0.00 0.00 0.00

Miscellaneous 0.00 0.00 0.00 0.00

Office Supplies 0.00 0.00 0.00 0.00

Postage 0.00 0.00 0.00 0.00

Printing 0.00 0.00 0.00 0.00

Shipping & Handling 0.00 0.00 0.00 0.00

Software/Hardware 0.00 0.00 0.00 0.00

Marketing & Public Relations 0.00 0.00 0.00 0.00

Website Hosting 0.00 0.00 0.00 0.00


Statement of Income and Retained Earnings

For the Twelve Months Ending December 31, 20##

12/3/2012 at 1:18 PM Page: 1For Management Purposes Only

Appendix-M Income and Expense Statement Template

Current Month Year to Date

Board Meetings 0.00 0.00 0.00 0.00

Committee Meetings 0.00 0.00 0.00 0.00

Government Advocacy 0.00 0.00 0.00 0.00

Rent 0.00 0.00 0.00 0.00

Taxes & Licenses 0.00 0.00 0.00 0.00

Telephone/Internet/Conference Call Expenses 0.00 0.00 0.00 0.00

Conference Expense

Audio Visual 0.00 0.00 0.00 0.00

Decor/Exhibit Company 0.00 0.00 0.00 0.00

Design/Artwork 0.00 0.00 0.00 0.00

Entertainment 0.00 0.00 0.00 0.00

Equipment Rental 0.00 0.00 0.00 0.00

Function Room Rental 0.00 0.00 0.00 0.00

Meals 0.00 0.00 0.00 0.00

Miscellaneous 0.00 0.00 0.00 0.00

Music Royalty 0.00 0.00 0.00 0.00

Registration Supplies 0.00 0.00 0.00 0.00

Photography 0.00 0.00 0.00 0.00

Postage 0.00 0.00 0.00 0.00

Printing 0.00 0.00 0.00 0.00

Program Planning Committee 0.00 0.00 0.00 0.00

Security 0.00 0.00 0.00 0.00

Shipping & Handling 0.00 0.00 0.00 0.00

Speaker Travel 0.00 0.00 0.00 0.00

Speaker Honoraria 0.00 0.00 0.00 0.00

Special Event/Activity 0.00 0.00 0.00 0.00

Total Expenses 0.00 0.00 0.00 0.00

Net Income 0.00 0.00 0.00 0.00

12/3/2012 at 1:18 PM Page: 2For Management Purposes Only

Appendix N- Committee Chair Job Description

1

ST Chapter of ASET – the Neurodiagnostic Society Committee Chair Policy

PURPOSE

To establish policy and responsibilities for committee and task force chair service.

POLICY

In order to support the mission, vision and values of the ST Chapter of ASET – the Neurodiagnostic Society, all volunteers, including committee

and task force chairs, must abide by the guidelines outlined herein.

PROCEDURE I. Committee and Task Force Chairs are appointed by the President

with approval of the Board of Directors. a. The term of appointment will correspond to the presidential

term, unless otherwise determined by the Board of Directors. b. Prospective Chairs will complete the Member Volunteer Form. c. Prospective chairs will be provided with of copy of the

following: i. Committee Chair Policy

ii. Committee Member Policy

II. Committee and task force members are selected by the Chair, subject to approval of the President.

a. The Chair will assure that prospective members receive the following:

i. Member Volunteer Form ii. Committee Member Policy

III. Chairs will receive assignments from the President and Board of

Directors and will develop a plan of action to accomplish the objectives set forth by the Board.

a. Chairs will:

i. Schedule meetings and conference calls; ii. Prepare and distribute meeting agendas and relevant

information to members; iii. Assure accurate minutes are recorded for all

meetings/conference calls b. The Chair will preside over meetings and/or conference calls

and ensure adherence to the major issues and goals of the committee and/or task force.

c. The Chair will inform members of the objectives and the individual committee member responsibilities and deadlines.

i. Chairs are responsible for maintaining a current list of member assignments and recording progress and dates

of completion.

Appendix N- Committee Chair Job Description

2

ii. Chairs are responsible for determining when deadlines can be extended or duties reassigned.

iii. Chairs will excuse members who are unable to attend meetings or conference calls when appropriate notice is

given.

IV. Because committee effectiveness diminishes when members fail to complete assignments in a timely manner and/or participate in

meetings, committee and task force Chairs are empowered to make needed changes to committee membership and assignments.

a. Committee or Task Force Chairs may excuse members from committee service in consultation with the President and/or

for appropriate cause, including, but not limited to, i. Failure to complete assignments on time or to request

an extension; ii. Unexcused absence from two or more meetings or

conference calls. b. Changes to committee or task force membership may be

appealed to the Board of Directors.

i. The Board of Directors holds the final authority on committee or task force membership.

V. The President in conjunction with the Board of Directors may make

needed changes to Chairmanship of committees or task forces for appropriate cause, including, but not limited to:

i. Failure to direct the work of the committee and/or task force to insure timely completion of assignments.

ii. Changes to committee or task force chairmanship may be appealed to the Board of Directors.

1. The Board of Directors holds the final authority on committee or task force membership.

Appendix O-Committee Work Plan

Developing a Committee Work Plan

Committee Instructions

As the work plan is developed by the committee, key issues are to be considered. It is important that the committee be realistic in their plan. It is

far better to select two or three key goals and be successful, rather than try and do everything and succeed at nothing.

1. First, the opportunity[ies] must be aligned with the strategic plan as

set forth by the Chapter Board of Directors. The goals and objectives must be planned to support its mission and advance its values. Be

mindful that strategies may continue for several years. For comprehensive tasks/plans, it may be necessary to include

attachments further outlining the comprehensive plan.

2. The plan should be mechanisms to measure success – a numerical

quantitative means of determining performance compared with the milestones and targets set.

3. Milestones must be determined, with expected results along the way

to accomplish a work plan. Milestones are expected to be established for no less frequently than monthly time periods.

4. Periodic reports that depict the status of the work plans and the

performance compared with the milestones and targets set, allowing corrective action and continuous quality improvement are required.

These can be in the form of committee meeting notes taken from conference calls, statistical reports provided by the membership

committee; etc. Written reports are expected to be provided to the board in preparation of board meetings.

Building the Plan

Goals [Outcomes] Describe the outcomes your committee will achieve for its stakeholders

[members, customers, the Chapter itself, etc.]. Three-year time frame reviewed every year by the board.

The following criteria can be used to evaluate the draft goal(s):

Necessary…responsive to an area of strategic importance; Feasible…will be able to make progress toward achieving the big, audacious goal;

Appropriate…for us as an organization; Sufficient…all areas of strategic importance have been included.

Appendix O-Committee Work Plan

Objectives [Directions]

Describe what you want to have happen with an issue. What would constitute success in observable or measurable terms? Indicates a direction

– increase, expand, decrease, reduce, consolidate, abandon, improve, distribute, enhance. Three-year timeframe reviewed every year by the

board.

Strategies [Actions]

Describe how the Chapter will commit its’ resources to accomplishing the goal. Brings focus to operational allocation of resources. Indicates an activity

– redesign, refine, identify, revise, develop, implement, create, establish. One-to-three year timeframe reviewed every year by the board. Serves as a

link from long-term planning to annual planning. Sets strategic priorities and helps develop annual action plan.

Setting Priorities

High Work on this strategy must be undertaken in the next program/fiscal year.

Middle Work on this strategy should be undertaken in the next program/fiscal year

if at all possible. Low Work on this strategy can wait until a subsequent

program/fiscal year if necessary.

Appendix P-Volunteer Enrollment Form Insert Logo

MEMBER VOLUNTEER FORM …helping grow the Chapter!

All organizations flourish with active and dedicated member leaders. We invite you to grow with us, as you contribute to the neurodiagnostic profession. We guarantee you’ll benefit both on a personal and professional level and we deeply appreciate your interest. (ST) Chapter of ASET – The Neurodiagnostic Society strives to match your interests, skills and professional knowledge with the needs of each committee or other leadership opportunities. The following questions will help us determine how we can best utilize your talents and interests. Every effort will be made to place you on the committee or activity of your choice.

PERSONAL INFORMATION

Name______________________________________________________________________________________________ Check appropriate credentials, if any:

R. EEG T. R. EP T. RPSGT CNIM R. NCS T. LPN Other ________________________________________

Check appropriate degrees, if any: 2 year Associates Degree BA BS MA MS MEd PhD Other __________________________________

Title/Position________________________________________________________________________________________

Employer___________________________________________________________________________________________ The following address is my preferred mailing address and it is: Home Work Address

Address____________________________________________________________________________________________

City, State, Zip______________________________________________________________________________________

Daytime Phone________________________________________ E-mail_______________________________________ Please note that some committee work is conducted via conference calls and email. If email is NOT the preferred method of communication, please check here and we will try and accommodate your needs.

1. List areas of interest in which you would like to serve as a member leader.

If you list more than one, indicate your first preference as “1” and so on. Chapter newsletters

Education

Governmental Advocacy

Membership & Awards

Annual Conference & Meetings

Public Relations & Marketing Board & Leadership Development Finance

2. Special skills and areas of expertise that you possess: [Check all that apply]

Basic Research Publicity/public relations Political involvement

Educational & program development Sales/marketing Other __________________

Financial/investments Speaker/teaching [i.e. president of PTA; church finance Fundraising Website development committee member; etc.]

Management/Human Resources Writing

3. What is your predominant professional activity? [Check all that apply] EEG IONM Nursing Research EP PSG Respiratory Other __________________

NCS LTM Management

4. I have the support of management to devote time to an (ST) Chapter ASET committee.

American Society of Electroneurodiagnostic Technologists, Inc. [ASET]

6501 East Commerce Avenue, Suite 120, Kansas City, MO 64120

Federal ID # 74-1553534 816.931.1120 phone 816.931.1145 fax [email protected] www.aset.org

updated 1/3/07

MEMBER VOLUNTEER FORM Page 2

Commitment I have read the committee descriptions provided and understand the level of involvement required for the

committees I have selected above. I understand that (ST) Chapter of ASET does not normally fund any expenses for committee activities. I also understand that I must be a current (ST) Chapter of ASET member to participate

on a committee.

Signature ____________________________________________Date ________________________________ [Electronic signatures accepted]

Supporting documents, including committee job and member descriptions, and other details will be forwarded to you

upon receipt of this application.

Please forward your information to Name of Member, Chair of the Name of Volunteer Recruitment Committee email address or fax to ###.###.####.

mailto:email

Appendix Q-Committee Member Policy

1

ST Chapter of ASET – the Neurodiagnostic Society

Committee Member Policy

PURPOSE To establish policy for committee and task force member service.

POLICY

In order to support the mission, vision and values of the ST Chapter of ASET – the Neurodiagnostic Society all volunteers, including

committee and task force members, must abide by the guidelines outlined herein.

PROCEDURE

I. Prospective volunteers will complete the Member Volunteer Form.

a. Prospective volunteers will be provided with of copy of the

following: i. Committee Member Policy

II. Committee and task force members will report their progress or

completion of assignments by the date established to the Committee or Task Force Chair.

a. Members who encounter problems related to fulfillment of their duties are to contact the Chair to arrange for an

extension or reassignment.

III. Committee and Task Force members are expected to participate in meetings and/or conference calls as scheduled by the Chair.

a. Members who are unable to attend meetings or conference calls will report their inability to attend to the Chair as

early as possible.

IV. Because committee and task force effectiveness diminishes when

assignments are not completed in a timely manner changes in membership or leadership of committees and task forces may be

necessary. a. Chairs are empowered to make needed changes to

committee assignments and/or membership i. Committee or Task Force Chairs may excuse

members from committee service in consultation with the President for appropriate cause, including,

but not limited to: 1. Failure to complete assignments in a timely

manner or to request an extension;

Appendix Q-Committee Member Policy

2

2. Unexcused absence from two or more

meetings or conference calls. ii. Changes to committee or task force membership

may be appealed to the Board of Directors. 1. The Board of Directors holds the final authority

on committee or task force membership.

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