Complete before February 4, 2019

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* 1. Chapter Information

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* 2. Name of Person Completing Form

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* 3. Chapter Officers and Directors

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* 4. Additional Officers and Directors (Please List in Box Below)

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* 5. Chapter Membership Numbers

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* 6. What Do You Charge for Membership (convert to USD)

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* 7. Comments or Additional Information About Your Membership

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* 8. Financial Information for Most Recent Fiscal Year End (convert to USD)

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* 9. Chapter Events - Complete the 2019 Chapter Events Survey

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* 10. Comments

If you require a copy of your recertification form for your records, please email Joey Broccolo at JBroccolo@ACFE.com

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