Member Resignation

Name(Required)

First Last

Effective Date of Resignation(Required)

What is your reason for resigning?(Required)

Are you committed to attending meetings regularly per the attendance policy until your effective resignation date?(Required)

Yes

Are you able to accept and handle any referrals you may receive until your effective resignation date?(Required)

Yes

Are you able to pass referrals untul your effective resignation date?(Required)

Yes

Signature(Required)