TO: Director of Local Chapters, IPMS/USA

The _IPMS ___________________________chapter requests payment of a cash supplement be made as host of the Regional Convention in

Region #_______

The convention to be held on (date):____________________

We understand that IPMS/USA cash supplements are paid to host chapters to encourage national member participation at Regional Conventions by reimbursing registration discounts to such members, and also to encourage junior participation. (There is only one “regional” per region per year, designated as such by the appropriate Regional Coordinator).

We guarantee the following three conditions: (1) any current IPMS/USA national member who identifies himself by membership card will receive a discount on his basic contest registration fee of at least 25% or $2, whichever is larger; (2) prominent notice of this will be made at registration and in advertising, and (3) contest junior categories will be available.

We request the standard supplement of $200, paid in advance of our event. If the total of member registration discounts allowed exceeds $200, we understand that the national society will provide funds matching the difference, on presentation of a list of names and member numbers of all IPMS members who received registration discounts, and the amounts allowed.

Print or type exact name for check to be written and address where it is to be mailed:

Name: ___________________________ __(as it is to appear on the check from IPMS/USA)

Street:_______________________________

City: _______________________________

ST: ________________________________

ZIP_________________________________

IPMS # of person receiving the check:
IPMS # _________Name of person receiving the check_____________________________

Print or type name, title and IPMS# of chapter official making request and date of request:

Name:_____________________________

Title:_____________________________

IPMS # ______

____________________________________________ __________________________ Signature Phone/e-mail address

RETURN this completed form to:

Dick Montgomery

IPMS Director of Local Chapters

8327 Timber Bough

San Antonio, TX 78250

Questions? Call 210-681-7945 or e-mail dlc@ipmsusa.org

OFFICE ONLY:
Director Local Chapters ____________________________(Initials) Date:__________________

Treasurer: Check No. ______ Amount ___________ Date________Treasurer_________(initials)