620 Park Avenue #311
Rochester NY 14607-2943
585-360-4512 local | 800-462-9498 toll-free
585-486-6529 fax | e-mail

Integrity gives thanks for the generous support of the...

Evelyn and Walter Haas, Jr. Fund

E. Rhodes and Leona B. Carpenter Foundation

Petition for Certification as a Chapter of Integrity Form

We, the undersigned, are dues-paid members in good standing of Integrity. Integrity was granted chapter-in-formation status on . We have at least 10 members. We have met at least once in the past two months. We have adopted chapter bylaws in accordance with the national bylaws of Integrity and elected officers. We submitted a Annual Chapter Report this year.

We respectfully submit the attached chapter bylaws and formally request certification as a chapter of Integrity.

The date of this petition is:

Signatures of Officers	Names	Addresses
`______________________________`Convener
`______________________________`Treasurer
`______________________________`Secretary

Complete this form, print it, and mail it to your regional vice president, the national secretary, and the Rochester address below. Don't forget to attach your chapter bylaws!

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