Officers for the  school year (please insert year – example: 2010-2011)
Complete Name of PTA or PTSA or Council
School Address
City Zip Code
School Type (select one) Select One Primary Elementary Intermediate Junior High Middle School High School Combined
Location Name (Name of City or County)
Region Select Region Blue Ridge Central Northern Southside Southwest Tidewater     District Select District Big Walker Dan River Eastern Shore Northern Virginia Fredericksburg Holston Hunt Hunt II James River Lynchburg Meherrin River Natural Bridge Natural Tunnel Parkway Peninsula Purple Rappahannock Valley Richmond Roanoke Shenandoah Southeastern Tidewater
LUR# - Local Unit Resource Number Located on Membership Card 
  (Enter 8 numbers that begin with 0s - don't leave blank)
EIN (Employer Identification Number)
  (If EIN is unknown enter 00-0000000, don't leave blank)

PRINCIPAL (select one) Dr. Mr. Mrs. Miss Ms.
Name 
Email Address     Bulletin Select One Online Email Mail Not at All

LOCAL UNIT PRESIDENT (select one) Mr. Mrs. Miss Ms.
Name
Home Address
City Zip Code
Work Phone with Area Code [eg ddd-ddd-dddd]
Home Phone with Area Code [eg ddd-ddd-dddd]
Email Address     Bulletin Select One Online Email Mail Not at All

TREASURER (select one) Mr. Mrs. Miss Ms.
Name 
Home Address
City Zip Code
Work Phone with Area Code [eg ddd-ddd-dddd]
Home Phone with Area Code [eg ddd-ddd-dddd]
Email Address     Bulletin Select One Online Email Mail Not at All

OTHER POSITIONS

TITLE (select one) Mr. Mrs. Miss Ms.
Name
Home Address
City Zip Code
Work Phone Home Phone
Email Address Bulletin Select One Online Email Mail Not at All

TITLE (select one) Mr. Mrs. Miss Ms.
Name
Home Address
City Zip Code
Work Phone Home Phone
Email Address Bulletin Select One Online Email Mail Not at All

TITLE (select one) Mr. Mrs. Miss Ms.
Name
Home Address
City Zip Code
Work Phone Home Phone
Email Address Bulletin Select One Online Email Mail Not at All

TITLE (select one) Mr. Mrs. Miss Ms.
Name
Home Address
City Zip Code
Work Phone Home Phone
Email Address Bulletin Select One Online Email Mail Not at All

TITLE (select one) Mr. Mrs. Miss Ms.
Name
Home Address
City Zip Code
Work Phone Home Phone
Email Address Bulletin Select One Online Email Mail Not at All