Form Designer

Member Function Request (IRS) Form

Event Name

Name of Contact Person

Event Start Time

Event End Time

LOCATION

Location of Event:

MEMBER INFORMATION

First Name:

Last Name:

Member number: *

Phone Number:

Date of Function: *

Email Address:

Number of Member Attendees

Number of Non-Member Attendees

Total Number of Attendees:

Please select ONE of the following options:

MEMBER(S)

[A] This Function will be paid for by me without reimbursement

Amount $

EMPLOYER

[B] This Function will be reimbursed to me by my employer for all or part of the charges

Amount $

Employer’s Name

Description of Group

Employer’s Address

Member’s Position in Firm

Purpose of Function

NON-MEMBER Relative/Friend/Organization (A Room Rental Fee May be Applicable)

[C] I will be reimbursed by a Non-Member other than my employer

Amount $

Person’s or Organization’s Name

Relationship to Member

Purpose of Function

Please sign here

Member's Signature *

Date: