2019 Chapter Recertification Form Consult with your board and submit one form per chapter. Please complete by February 3, 2020. Question Title * 1. Chapter Information Chapter Name and Number Chapter Web Address Chapter Email Address Chapter Phone Number Chapter Mailing Address Question Title * 2. Name of Person Completing Form Question Title * 3. Chapter Officers and Directors President Vice President Secretary Treasurer Training Director Director Director Director Director Question Title * 4. Additional Officers and Directors (Please List in Box Below) Question Title * 5. Has your chapter formed committees? If so, please list them below. Question Title * 6. Chapter Membership Numbers Total Members CFEs Associates Students Affiliates Other Question Title * 7. Did your membership increase or decrease since last year? Increase Decrease Question Title * 8. How much did your membership change by? Please enter it as a percentage. Question Title * 9. What Do You Charge for Membership (convert to USD) CFEs Associates Student Members Affiliates Other Pricing Structure? Question Title * 10. Comments or Additional Information About Your Membership Question Title * 11. Financial Information for Most Recent Fiscal Year End (convert to USD) Revenue Expenses Cash on Hand Date of Fiscal Year End Question Title * 12. Chapter Events - Complete the 2020 Chapter Events Survey Already submitted. Will complete before February 3, 2020 Other (please specify) Question Title * 13. Comments If you require a copy of your recertification form for your records, please email Joey Broccolo at JBroccolo@ACFE.com Done
