SkillsUSA Membership Roster

®
SkillsUSA Membership Roster
NATIONAL COPY
If you join through our Web site, you do not need to ﬁll out this form.
Arrival Date:
4/13
STATE COPY
Check instruction booklet for your state dues and deadlines.
F O R M 10
Name
and
Address
Drops and substitutions are not allowed. Deadline: March 1, 2014
1. Please provide your training area, name and school address and contact information.
E-mail Address: __________________________________
Phone: __________________________________________
TRAINING AREA YOU TEACH:
Fax: ____________________________________________
ADVISOR NAME:
School District: ___________________________________
SCHOOL NAME:
(High school only. Does not apply to college/postsecondary.)
SCHOOL ADDRESS:
Chapter No.: ____________________________________
CITY, STATE, ZIP CODE:
Chapter
Summary
(If applicable to your state.)
2. How many students are enrolled in your class?
TCheck box if 100% of the class is registered in SkillsUSA.
How many of the SkillsUSA members are: Black/African-American_____
White/Caucasian_____
American Indian/Alaska Native_____
Native Hawaiian/Other Paciﬁc Islander_____
How many of the SkillsUSA members are: Males_____
Dues
Summary
See Web site or
membership kit for
a list of state dues
and state deadlines.
a. W
3.
No. of Members
Asian_____
Hispanic/Latino/Spanish_____
Multicultural_____
Other_____
Females_____
b. W
c. (a x b) W
National Dues Rate
National Dues Paid
d. W
e. (a x d) W
State Dues Rate
f. (c + e) W
State Dues Paid
Total Dues
STUDENT
High School
$8.00
$
$
$4.00
$
$
College/PS
$8.00
$
$
$4.00
$
$
$14.00
$
$
$
$
$
$
PROFESSIONAL
High School
College/PS
$14.00
$14.00
Total Members
$
$
$
$
Total National Dues
$2.00
$2.00
$
Total State Dues
TOTAL DUES PAYMENT
Dues include $1.30 for one-year subscription to SKILLSUSA CHAMPIONS magazine.
Student
Members
Check HS for high
school or C/PS
for college/
postsecondary
4. LIST YOUR STUDENT MEMBERS Drops and substitutions are not allowed. If you prefer, you may attach a typed list or computer printout.
NAME
ADDRESS (include city, state and ZIP code)
HS C/PS
You may use the
school address, but
please provide a home
address if required by
your state.
Professional 5. LIST YOUR PROFESSIONAL MEMBERS Drops and substitutions are not allowed. If you prefer, you may attach a typed list or computer printout.
Members
NAME
ADDRESS, IF OTHER THAN SCHOOL (include city, state and ZIP code)
Check HS for high
school or C/PS
for college/ps.
You may use a school
address or
a home address.
Mailing Instructions: Send a roster with your check or money order payable to SkillsUSA. Questions? Call 800-355-8422
Mail to: SkillsUSA Inc., Attn: Membership, 14001 SkillsUSA Way, Leesburg, VA 20176
Download additional paper roster forms from: www.skillsusa.org/downloads/PDF/memberkit/roster.pdf
HS C/PS

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