Extension Homemakers County/Council Officer and Leader Mailing List FCS 376 (11-2016)
This form can be used to record Club officers and Council officers.
Indicate below whether County or Council. Complete one form for Council and one form for each Club in your county.
County	Year
If Club, Name of Club	Club EIN #
Council (same as County)	Council EIN #
This form, to be completed annually and signed by the President and Secretary of the County Extension Homemakers Council, should be copied to the County Secretary’s book and a copy given to your County FCS agent by July 1. One copy of this form should also be submitted to the Melody Curtis at the state office by August 1 of each year. For reporting club officers, Club Secretaries should forward, by July 1, a copy of the below list to your County Agent and a copy by August 1to Melody Curtis at the state office. Lists can be faxed to: Melody Curtis, 501-671-2294, or call 501-671-2012. Can be emailed to mcurtis@uaex.edu or mailed to 2301 S. University, Little Rock, AR 72204.
County/Club Officer	Name	Street Address, or	Home and
Email	Route and Box Number	Cell Phone
Example:	Jane Doe	1234 Main Street,	501-671-2012
jd@uaex.edu	Little Rock, AR 72205	501-555-1234 (cell)
President
Vice President
Secretary
Treasurer
EIN Representative (Council Only)
Past President
Other
Other
Other

Club/Council President’s Signature	Date
Club/Council Secretary’s Signature	Date

Include Others (i.e. Education Chair, Song Leader, etc).