Branch Name: Merrimack Valley                          Chapter Number: 199

The SCORE Association
Counselors to America's Small Business
Application for Membership

NAME:  (  LAST, FIRST, MIDDLE  ) 
     
Permanent Address
City, State, ZIP        
Temporary Address 
City, State, ZIP        
Home Phone           

Social Security Number        
Spouse's Name (optional)     

Dates at Temporary Address  
E-Mail Address                       
Facsimile                               

Membership Standards

To Be a Member of SCORE In Good Standing I Agree to:

1. Provide confidential counseling and training to small business people, as well as other services to 
   SCORE without any claim to compensation, honoraria or things of value for my services. I may be 
   reimbursed for my authorized expenses while on SCORE business.

2. Comply with the SCORE Code of Ethics, which I will read and sign prior to my introductory period 
   and each year thereafter.

3. Adhere to the SCORE Operating Manual (SOM) and Chapter by-laws including any attendance and
   participation requirements necessary to remain an active member of the chapter.

4. Actively participate in SCORE activities and accept reasonable assignments to assist in the 
   management and administration of the chapter's operation.

Statement of Understanding and Certification:
I understand that SCORE has a 90-day introductory period, during which I will receive orientation and 
training and that my SCORE membership, if I fail to fulfill my responsibilities as a SCORE member. I certify 
that all of the statements on this application are true and complete.

Signature and Title of Requestor:          Date: (mm/dd/yyyy)