Membership Transmittal (Online) – Union of Black Episcopalians

UBE Membership Transmittal Report

Name of Chapter

Name of Reporter (Electronic Signature - please type full name)

Number of Membership Applications Submitted:

Date

Last Name

First Name

Middle Initial

Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Home Phone Number

Cell Phone Number

Other Phone Number

Email Home

Email Work

Parish

Membership Type

Individual Family Retired Youth

Amount Collected $

Paid National $

Paid Chapter Dues $

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Summary

Name of Chapter

Name of Reporter (Electronic Signature - please type full name)

Total Number of Members Reported

Total Number of Youth Members Reported:

Total Number of New Members Reported:

Totals:

National - Total Collected for individual membership: $

Chapter - Total Collected for individual membership: $

National - Total Collected for family membership: $

Chapter - Total Collected for family membership: $

National - Total collected for retired membership: $

Chapter - Total collected for retired membership: $

National - Total collected for youth (under 21): $

Chapter - Total collected for youth (under 21): $

National - Total collected for Life membership: $

National - Total collected for sponsor (church): $

National - Total collected for sponsor (organization): $

National - Total collected for sponsor (associate): $

Chapter yearly assessment $

National - Total Collected for individual membership: $

Totals:

Totals collected for National: $

Totals collected for Chapter: $

Grand Totals: $

UBE Membership Transmittal Report

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