2013 MEMBERSHIP INFORMATION FORM (PLEASE PRINT OR TYPE YOUR DISTRICT INFORMATION FOR CLARITY)

SCHOOL or DISTRICT _____COUNTY ______CTD#__________________

DISTRICT TYPES: Please circle your district type.

ACTIVE MEMBER: (Public School District)

ASSOCIATE MEMBER (Accommodation Schools, State School for the Deaf & Blind, Agency, BIA, and Tribal schools, State

Juvenile Education System Board, Charter School Boards, and Community College Governing Boards)

CENTRAL OFFICE PHONE _ ____________ACCOUNTS PAYABLE PHONE _________________________

CENTRAL OFFICE FAX ________________________________

CENTRAL OFFICE EMAIL ________________________SCHOOL WEBSITE_________________________________

MAILING ADDRESS______________________________________________________________________________________

CITY________________________STATE______________________________ZIP_____________________

CURRENT SUPERINTENDENT_______________________________EMAIL_________________________

SUPERINTENDENT HIRE DATE:______________________________________________________________________________

SUPERINTENDENT SECRETARY_______________________________EMAIL__________________________

BUSINESS MGR/FISCAL OFFICER ____________________________________ EMAIL__________________________________

STUDENT ENROLLMENT: _______________

THE FOLLOWING INFORMATION IS NEEDED TO COMPUTE THE ANNUAL ASBA DUES FOR THE ORGANIZATION. **NOTE: Per auditor request, please attach a copy of the budget work sheets as noted below in (1) and (2). ** (1) TOTAL MAINTENANCE AND OPERATION BUDGET AMOUNT $____________________________ (Re: #1 – M & O for Public schools, see work sheet page 1 line 30 for the Total M & O Budget Amount using Budget FY 2013 number) (Re: #1 – M & O for Charter schools, see work sheet page 1 line 33 for the Total M & O Budget Amount using Budget FY 2013 number)

(2) TOTAL SPECIAL PROJECTS (A.R.S. 15-903) BUDGET AMOUNT $____________________________ (Re: #2 – For Public Schools -expenditure budget work sheet page 6 line 30 for the Total Special Projects Budget Amount using Budget Year number) (Re: #2 – For Charter Schools -expenditure budget work sheet page 1 line 38 for the Total Federal and State Projects Budget Amount using Budget FY 2013 number)

THE CENTRAL OFFICE IS LOCATED IN:

ALL STATE LEGISLATIVE DISTRICTS LOCATED (EITHER ENTIRELY OR IN PART) WITHIN BOUNDARIES OF YOUR SCHOOL DISTRICT #___________

ARIZONA STATE LEGISLATIVE #_________,

U.S. CONGRESSIONAL DISTRICT #_________ (Visit www.azleg.gov and click on “How Do I find my Legislators” on the left side.)

DAY(S) OF REGULAR BOARD MEETINGS____________________________________________

TIME OF REGULAR MEETINGS ___________________________________________________

NAME OF PERSON COMPLETING THIS FORM____________________________________________________________________

EMAIL ADDRESS:____________________________________________________________________

(CONTINUE TO GOVERNING BOARD MEMBERS INFORMATION ON NEXT PAGE)

2013 GOVERNING BOARD INFORMATION

SCHOOL OR DISTRICT: _____________________ NAME:

PRESIDENT VICE-PRESIDENT CLERK MEMBER

EMAIL:

OCCUPATION:

GENDER:

OFFICE PHONE

FAX:

HOME/CELL PHONE:

TERM EXPIRES:

YRS. ON BOARD: _

HOME ADDRESS:

NAME:

PRESIDENT VICE-PRESIDENT CLERK MEMBER

EMAIL:

OCCUPATION:

GENDER:

OFFICE PHONE:

FAX:

HOME/CELL PHONE:

TERM EXPIRES:

YRS. ON BOARD:

HOME ADDRESS:

NAME:

PRESIDENT VICE-PRESIDENT CLERK MEMBER

EMAIL:

OCCUPATION:

GENDER:

OFFICE PHONE:

FAX:

HOME/CELL PHONE:

TERM EXPIRES:

YRS. ON BOARD:

HOME ADDRESS:

NAME:

PRESIDENT VICE-PRESIDENT CLERK MEMBER

EMAIL:

OCCUPATION:

GENDER:

OFFICE PHONE:

FAX:

HOME/CELL PHONE:

TERM EXPIRES:

YRS. ON BOARD:

HOME ADDRESS:

NAME:

PRESIDENT VICE-PRESIDENT CLERK MEMBER

EMAIL:

OCCUPATION:

GENDER:

OFFICE PHONE:

FAX:

HOME/CELL PHONE:

TERM EXPIRES:

YRS. ON BOARD:

HOME ADDRESS:

PLEASE TYPE OR PRINT your governing board members information for clarity. Please indicate your board members title (e.g. President or Member) and email address to keep your members updated and receive ASBA’s correspondence in electronic format. Thank you for your assistance and return to the ASBA Office, 2100 N. Central Avenue, Ste. 200, Phoenix, AZ 85004 or email to ewhite@azsba.org .

O: 602.254-1100 or F: 602.254.1177