Uap Membership Transfer Form
Uap Membership Transfer Form
Uap Membership Transfer Form
A. PERSONAL INFORMATION
FAMILY NAME FIRST NAME MIDDLE NAME
CURRENT PHOTO
BIRTHDATE (MM/DD/YYYY) BIRTHPLACE SEX CIVIL STATUS (1.5” X 1.5”; white background)
NAME OF COMPANY AND ITS OFFICIAL ADDRESS TEL NO/s. FAX NO/s. EMAIL ADDRESS
DESIGNATION
B. TRANSFER INFORMATION
1. REASON FOR TRANSFERRING CHAPTER AFFILIATION 2. TYPE OF TRANSFER
Change of Residency Change of Workplace
Others (please specify) PERMANENT TRANSFER
TEMPORARY TRANSFER
(under Fostering Chapter Policy)
3. TRANSFER CHAPTER AFFILIATION EFFECTIVE (MM/DD/YYYY)
PREVIOUS CHAPTER
CHAPTER NAME
ADDRESS
TELEPHONE NO/s. EMAIL ADDRESS
CHAPTER PRESIDENT MOBILE NO.
NEW CHAPTER
CHAPTER NAME
ADDRESS
TELEPHONE NO/s. EMAIL ADDRESS
CHAPTER PRESIDENT MOBILE NO.
AUTHORIZATION TO TRANSFER
By the power vested upon me by the UAP By-Laws as Chapter President and upon the evaluation of the applicant’s Membership Status with the
Chapter, I hereby accept the transfer of Arch. ____________________________ to our Chapter, subject to our Internal Rules and Regulations.
_______________________________________________ ____________________________
Signature Over Printed Name of Chapter President Date
APPLICANT’S CERTIFICATION. I hereby certify and declare under the penalties of perjury, that all the information herein is a Applicant’s Signature and Date
true statement of my personal and professional information as of this date, as required by and in accordance with the UAP By-
Laws and its Implementing Rules and Regulations.
DON’T FILL-OUT THIS PORTION (FOR UAP NATIONAL ADMINISTRATION USE ONLY)
Verification of Information/Data Recommending Approval: Approved by Data Encoded by
UAP National Admin – Membership Division Executive Director, Internal Affairs UAP Secretary General UAP National Admin – Membership Division
Membership Form Rev 06.28.22