**OMB APPROVED**

**No. 3206-0131**

> ![](media/image1.png)Combined Federal Campaign

**2008 Application Instructions for**

**Local Federations**

#### Background

Enclosed is the model application for use by local federations applying
to participate in the Combined Federal Campaign (CFC). A federation is a
group of voluntary charitable human health and welfare organizations
created to supply common fundraising, administrative, and management
services to its constituent members. A federation must have at least 15
member organizations, in addition to itself, that individually meet all
of the CFC eligibility criteria. If your organization does not have 15
member organizations that meet the CFC eligibility criteria, it must
apply as an independent organization using the independent organization
application.

The following instructions and form are intended to assist charitable
federations in applying for participation in the CFC. All aspects of the
CFC, including eligibility for par­ticipation, are strictly governed by
Federal regula­tion. Copies of current CFC regulations are avail­able in
PDF and Word formats on our website at www.opm.gov/cfc. Additional
copies of the application can also be downloaded from the website.

All required documents and attachments must be complete and submitted
before the application deadline each year. ***Applicants whose
applications do not contain documents or who submit** **in-complete or
out-of-date documents will not be permitted to correct their
applications during the appeals process*****.** Federations that apply
for local eligibility and are found ineligible will have an opportunity
to appeal to the Local Federal Coordinating Committee (LFCC) for
reconsider-ation. If found ineligible on appeal by the LFCC, the
federation may appeal the LFCC's decision to the Direc­tor of the Office
of Personnel Manage-ment (OPM). The Director\'s decision is final for
administrative purposes. Appellants should insure that their appeals are
complete and respon­sive to the actual reasons for the LFCC denial
decision.

Each LFCC determines the application deadline for fed­erations seeking
local eligibility. Since local dates will vary, please check with the
local CFC for local application deadlines and filing information. Local
campaign contact information can be found on the CFC website at
www.opm.gov/cfc/Search/Locator.asp.

If a local application form is available, OPM sug­gests that federations
use the local application pro­vided when applying to the Combined Federal

Campaign (CFC).

The CFC will not accept application forms with modifications to any of
the certification statements.

In order to determine whether a federation may participate in the
campaign, the LFCC may request evidence of corrective action regarding
any prior violation of regulation or directive, sanction, or penalty, as
appropriate. The LFCC will decide whether the federation has
demonstrated, to the LFCC's satisfaction, that the federation has taken
appropriate corrective action. Failure to demon-strate satisfactory
corrective action or to respond to the LFCC's request for information
within 10 business days of the date of the request may result in a
recommendation that OPM withdraw federation status. The Director's
decision will be communicated in writing to the federation.

**FAXES OR ELECTRONIC SUBMISSIONS OF APPLICATIONS ARE NOT ACCEPTED**

##### DEFINITIONS

###### 

**Federation** Legal name of the applicant federa­tion. If the name of
the federation is different from the name which appears on the IRS
determination letter, IRS Form 990, audited financial statements, or
annual report, official documentation from the IRS or a state government
authorizing use of this name must accompany the application. The EIN
must be included.

**Employer Identification Number (EIN)** The nine-digit EIN that appears
on the IRS determination letter and the IRS Form 990 submitted with this
application.

**5 Digit CFC Number** The 5 digit number assigned to the federation.
New 5 digit numbers were assigned to organizations that participated in
the 2007 CFC for use in that campaign and future campaigns. Federations
that did not participate in the 2007 CFC should leave this field blank.

**Mailing Address** A physical mailing address must be provided - Post
Office Box addresses will not be accepted.

**Telephone** Organization's telephone number.

**Contact Person** The contact person is the indi­vidual to whom the CFC
will direct communica­tions. This may be any individual in the
organi­zation.

**Contact Address** Contact person's physical

mailing address if different than the organization\'s

address. Post Office Boxes may be used. Participation decision letters
and other CFC communications will be sent to the contact person at this
address.

**Contact Telephone** Contact person's telephone number, if different
than the organization's number.

**Fax** Contact person's fax number.

**Contact E-Mail Address** Contact person's electronic mail address.

**Federation Website Address** List the complete Internet address of the
applicant federation (no e-mail addresses). This information is
required, if the organization has an Internet address.

**Disbursement Address** List the address where paper checks will be
sent, if different from mailing address. Post office boxes may be used
for the disbursement address.

**Electronic Funds Transfer (EFT) Information** List the Routing and
Account numbers, along with the name of the financial institution, where
funds should be disbursed. This is an optional method for receipt of CFC
contributions. NOTE: Some campaigns may elect not to disburse funds
electronically.

**Certifying Official** The certifying official is the individual who
has the authority to affirm that all statements in the application are
accurate.

***INSTRUCTIONS***

For details regarding CFC eligibility requirements for local
federations, refer to CFC Guidance Memoranda on the CFC website at
[www.opm.gov/cfc](http://www.opm.gov/cfc).

Applicants must check the box next to each certification statement to
demonstrate agreement to comply with the statement and to certify it
meets the requirement. Failure to provide a check mark for each of the
statements will be considered as a refusal to certify and will result in
the denial of the application.

**A New Federation Applicant** must submit, along with its application,
the complete applications of all member organizations.

**A Currently Participating CFC Federation Applicant** must submit a
complete application for itself as well as each member that is new to
the federation (regardless of whether it participated as an independent
organization or member of another federation in the 2007 CFC) and each
member denied participation in the 2007 CFC.

**Item 1**

**Include as *Attachment A* a list of all eligible member
organizations** meet all local eligibility criteria of 5 CFR §§§
950.202, 950.203, 950.204, and 950.401(i) for participation. Include
their legal names, EINs, administrative and fundraising rates, and the
local presence category under which each member is eligible for
participation in the local campaign (e.g. Local, Adjacent, or
Statewide).

**Item 2**

**Include as *Attachment B* a copy of the federation's most recent IRS
determination letter.** If the name of the applicant organization
differs on the IRS determination letter, the IRS Form 990, or audited
financial statements, documentation from the IRS or state government
authorizing this name change must accompany the application.

Units of government are not eligible to participate in the CFC.

**Each local federation and federation member's 501(c)(3) status will be
verified with the IRS. Federation applicants and federation members
whose current 501(c)(3) status cannot be confirmed by the IRS will be
denied participation. OPM encourages organizations to request current
letters from the IRS confirming the group's tax-exempt status. This
request can be made by contacting the IRS at (877) 829-5500.**

**Item 3**

Self-explanatory

**Item 4**

**Check the appropriate box. The federation's certifying official must
certify that the federation accounts for its funds on an accrual basis
in accordance with Generally Accepted Accounting Principles (GAAP) and
has an audit of its fiscal operations completed by an independent
certified public accountant in accordance with Generally Accepted
Auditing Standards (GAAS).** No other basis of accounting is acceptable
under Generally Accepted Accounting Principles (GAAP). The cash basis,
modified cash basis, and modified accrual basis are not acceptable
methods of accounting under GAAP.

**Include as *Attachment C* a copy of the federation's audited annual
financial statements.** The audited financial statements must cover the
fiscal period ending not more than 18 months prior to the January of the
campaign year to which the fed­eration is applying (i.e. ending on or
after June 30, 2006). **The audited financial statements must verify
that the federation is honoring designations made to each member
organization by distributing a proportionate share of receipts based on
donor designations to each member**.

The IRS Form 990 and audited financial statements must cover the same
fiscal period and be prepared using the accrual basis of accounting.

Newly created federations operating for less than one year (as
determined from the date of the IRS determination letter to the closing
date of the CFC application period) are not required to submit audited
financial statements.

**Item 5**

Check the appropriate box. **Include as *Attachment D* a copy of the
[complete, signed]{.underline} IRS Form 990 for a period ended not more
than 18 months prior to January 2008.** The IRS Form 990 must include a
signature in the block marked "Signature of officer"; the preparer's
signature alone is not sufficient.

A complete IRS Form 990 is required including all supplemental
state­ments and Schedule A, if applicable, for the applicant federation
to be eligible for the CFC. If the IRS does not require the federation
to file a Form 990 it must complete and submit a pro forma IRS Form 990,
page 1 and Part V only. IRS Forms 990EZ, 990PF, and comparable forms
will not be accepted. However, smaller federations that file Form 990EZ
may submit it with page 1 and Part V of the Form 990 attached in lieu of
a complete IRS Form 990.

The IRS Form 990 and audited financial state-ments must be prepared
using the accrual method of accounting and cover the same fiscal period
ended not more than 18 months prior to January 2008 (i.e. ended on or
after June 30, 2006).

**Item 6**

**Calculate and enter the federation's annual per­centage for
administrative and fundraising expenses.** This percentage is computed
from the IRS Form 990 submitted with this application by adding the
amount reported as \"management and general\" (line 14) to
\"fundraising\" (line 15) and dividing the resulting total by \"total
revenue\" (line 12). No other method may be used to calculate this
percentage.

### Item 7 

**Each federation must include as *Attachment E* a complete listing of
the federation's board of directors and the beginning and end dates of
each individual's current term of office (e.g. John Smith, 2004-2007).
*Attachment E* must also list the board's meeting dates and locations
for the previous year (2007).**

### Item 8 

Self-explanatory

### Item 9 

Self-explanatory

**Item 10**

Self-explanatory

**Item 11**

Self-explanatory

**Item 12**

**Include as *Attachment F* a copy of the federa­tion\'s most recently
completed annual report.** The annual report must cover the fiscal year
ending not more than 18 months prior to Janu­ary of the campaign year to
which the federation is applying or the preceding calendar year**.** A
more frequently published document, such as a quarterly newsletter, may
be substituted so long as it meets the requirements for the annual
report.

The annual report or more frequently published document must contain a
full description of the federa­tion's activities and supporting services
during the year covered by the report and identify its directors and
chief administrative personnel.

The annual report or more frequently published document must also
include an accurate description of the federation's membership dues
and/or service charges received by the federation from the charitable
organizations participating as members. The information must clearly
present the amounts raised, the sources of contributions, the cost of
fundraising, and how costs are recovered from donations.

Reproductions of annual reports that are available on a federation's
website are acceptable. The annual report must be clearly marked as such
on the website and must include all of the criteria outlined in the CFC
regulations (see above). OPM will not accept miscellaneous pages from
the federation's website that provide this information in lieu of an
annual report document. A printed copy of the report must be included in
the CFC application.

**Item 13**

Each federation and independent organization applying to participate in
the CFC must, as a condition of participation, certify that it is in
compliance with all statutes, Executive Orders, and regulations
restricting or prohibiting U.S. persons from engaging in transactions
and dealings with countries, entities, and individuals subject to
economic sanctions administered by the U.S. Department of the Treasury's
Office of Foreign Assets Control (OFAC).  The programs administered by
OFAC restrict or prohibit U.S. persons from engaging in transactions and
dealings with targeted countries, entities, and individuals.  OFAC
publishes a list of Specially Designated Nationals and Blocked Persons
(SDN List).  The persons on the SDN List are subject to economic
sanctions.  The SDN List and additional information relating to the
economic sanctions programs that OFAC administers are available at
<http://www.treas.gov/ofac>.  A link to the SDN List is available on the
CFC website ([www.opm.gov/cfc](http://www.opm.gov/cfc)).  For further
information, please see CFC Memo 2005-13.

**Item 14**

**Include as *Attachment G*, a statement in 25 words or less that
describes the federation's program activities.** The statement should
not repeat the federation\'s name. The federation must also provide the
legal name as registered with the IRS if the federation does business
under a different name. All federations must include their IRS Employee
Identification Number (EIN) regardless of whether or not they are
operating under a \"dba\" ("doing business as"). The federation must
also include a telephone number that can be reached from any location in
the U.S. and the federation's administrative and fundraising rate. The
legal name, telephone number, EIN, taxonomy codes and administrative and
fund-raising rate will NOT count as part of the 25-word statement. An
Internet address where information on the organization can be obtained
may be included and will not count toward the 25 words. OPM will not be
responsi­ble for incorrect Internet addresses. E‑mail addresses are not
accepted. ***Include in Attachment G the 25-word statements for all
member organizations.***

**Taxonomy Codes** Each federation can identify up to three categories,
in priority order, which most closely identify the type of mission,
services, and activities provided. The corresponding letters will be
printed in the organization's listing in the CFC charity list (see
example below) to assist donors in identifying charities by type of
service provided. Categories are derived from the National Taxonomy of
Exempt Entities (NTEE) classification system developed by the National
Center for Charitable Statistics. The 26 categories are:

A Arts, Culture, and Humanities

B Educational Institutions & Related Activities

C Envir. Quality, Protection & Beautification

D Animal Related

E Health -- General and Rehabilitative

F Mental Health, Crisis Intervention

G Disease, Disorders, Medicinal Disciplines

H Medical Research

I Crime, Legal Related

J Employment, Job Related

K Food, Agriculture, and Nutrition

L Housing, Shelter

M Public Safety, Disaster Preparedness & Relief

N Recreation, Sports, Leisure, Athletics

O Youth Development

P Human Services -- Multipurpose and Other

Q International, Foreign Affairs, National Security

R Civil Rights, Social Action, Advocacy

S Community Improvement, Capacity Building

T Philanthropy, Voluntarism & Foundations

U Science & Technology Research Institutes,

Services

V Social Science Research Institutes, Services

W Public, Social Benefit: Multipurpose, Other

X Religion Related, Spiritual Development

Y Mutual/Membership Benefit Orgs., Other

Z Other

Special design text used to draw attention to a federation title, such
as special fonts, capitaliza­tion, quotations, and underlining, are not
accepted. **Any statement that uses special features or exceeds 25 words
will be edited by the LFCC.** Federations will be listed by their legal
IRS recog­nized name as it appears on the IRS determination letter unless
the appropriate legal documentation permitting otherwise is provided
with the application. See Item 2. The format is as follows:

# 0000 Name of Federation (Legal Name of Federation, if applicable) (202)555-1234 www.opm.gov/cfc EIN#12-3456789 The description will contain no more than 25 words. It should be worded so the donor understands the program services provided. 4.2% B,V,O 

REQUIRED ATTACHMENTS (failure to provide any of these may result in a
denial)

-   **[A]{.smallcaps}ttachment A** [--]{.smallcaps} **documentation of
    local presence, adjacent presence, or statewide presence (See Item
    1)**

-   **Attachment B -- IRS determination letter (See Item 2)**

-   **Attachment C -- Audited Financial Statements (if required \-- See
    Item 4)**

-   **Attachment D -- IRS Form 990 (See Item 5)**

-   **Attachment E -- Board Members' Current Terms of Office and Meeting
    Dates and Locations (See Item 7)**

-   **Attachment F -- Annual Report (See Item 12)**

-   **Attachment G -- 25-Word Statements for Federation and Its Eligible
    Member Organizations (See Item 14)**

> OMB APPROVED
>
> NO. 3206-0131

Combined Federal Campaign

**[2008 Application for]{.smallcaps}**

**[Local Federations]{.smallcaps}**

Federation:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employer Identification Number (EIN): \_\_ \_\_ - \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_ \_\_ \_\_

5 Digit CFC Number (If a participant in the last year\'s CFC): **\_\_\_
\_\_\_ \_\_\_ \_\_\_ \_\_\_**

Mailing Address:

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> *(Post Office Box addresses are not accepted and may result in
> automatic disqualification.)*

Telephone Number [(
)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Contact Person:

Contact Address:

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> (*If different from the above address -- Post Office Box Addresses are
> acceptable for the Contact Address. All CFC correspondence will be
> sent to this address.)*

Contact Telephone: [( )\_\_\_\_\_\_\_\_\_\_\_\_ \_\_]{.underline} Fax:
[( )]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact E-Mail Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Federation Website Address (required, if available):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Disbursement Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*(This is the address where paper checks will be sent.)*

Electronic Funds Transfer (EFT) information (Optional):

RTN (9 digits): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ACCT:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Financial Institution:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1\) I certify that the federation named in the application has15 or more
member organizations

that individually meet all local eligibility criteria of 5 CFR §§§
950.202, 950.203, 950.204, and 950.401(i) for participation in this
campaign by having either a substantial local presence in the geographic
are served by the local campaign, a substantial local presence in the
geographic area served by an adjacent local campaign, or a substantial
statewide presence. **Include as *ATTACHMENT A* a list of all member
organiza­tions that meet this requirement.** The list must include each
organization (with its legal name in parentheses if using a "dba"),
Employer Identification Number (EIN), administrative and fundraising
rate, and the local presence category under which it is eligible for
participation in the local campaign (e.g. Local, Adjacent, or
Statewide).

2\) I certify that the Internal Revenue Service recognizes the
federation named in this application

> as tax-exempt under 26 U.S.C. 501(c)(3) and to which contributions are
> tax deducti­ble pursuant to 26 U.S.C. 170(c)(2). **Include as
> *ATTACHMENT B* a copy of the most recent IRS determination letter.**
> *See instructions for additional information.*

3\) I certify that the federation named in this application is a human
health and welfare

federation and either it or its member organizations provide services,
benefits, or assistance to, or conduct activities that directly or
indirectly affect, human health and welfare. The services, benefits,
assistance, or program activities affecting human health and welfare
were provided in 2007.

4\) Place a check in the ***one*** appropriate box:

> I certify that the federation named in the application accounts for
> its funds on an accrual basis in accordance with generally accepted
> accounting principles (GAAP) and has an audit of its fiscal operations
> completed annually by an independent certified public accountant in
> accordance with generally accepted auditing standards (GAAS).
> (**Include as *ATTACH-MENT C* a copy of the audited financial
> statement for a fiscal period ending not more than 18 months prior to
> January 2008** which verifies that the federation is honoring
> designations made to each member organization by distributing a
> proportionate share of receipts based on donor designations to each
> member.)
>
> \- OR -

I certify that the federation named in the application accounts for its
funds on an accrual basis in accordance with generally accepted
accounting principles (GAAP), but has been operating for less than one
year and therefore is not required to submit audited financial
statements.

5\) Place a check in the ***one*** appropriate box:

I certify that the federation named in this application prepares and
submits to the IRS a complete copy of the federation's IRS Form 990.
(**Include as *ATTACHMENT D* a copy of the complete IRS Form 990 for a
period ending not more than 18 months prior to January 2008**, including
signatures in the box marked "Signature of Officer". The preparer's
signature alone is not sufficient. IRS Forms 990EZ, 990PF, and
comparable forms are not acceptable substitutes.)

> \- OR -

I certify that the federation named in this application is not required
to prepare and submit an IRS Form 990 to the IRS. (**Include as
*ATTACHMENT D* a pro forma IRS Form 990 page 1 and Part V only** for a
period ending not more than 18 months prior to January 2008. IRS Forms
990 EZ, 990PF, and comparable forms are not acceptable substitutes.)

6\) I certify that the administrative and fundraising rate for the
federation named in this

application is \_\_ \_\_ . \_\_%.This percentage is computed only from
information on the IRS Form 990 by adding the amount spent on
\"management and general\" (line 14) to \"fundraising\" (line 15) and
divid­ing the resulting total by \"total revenue\" (line 12). No other
method may be used to calculate this percentage. All percentages must be
listed to the tenth of a percent (i.e. 10.0% or 15.5%).

7\) I certify that an active and responsible governing body, whose
members have no material

conflict of interest and a majority of whom serves without compensation,
directs the federation named in this application. (Include as
***ATTACHMENT E*** a list of the federation's board of directors with
the beginning and ending date of each board member's current term of
office. ***ATTACHMENT E*** must also list the board's meeting dates and
locations for calendar year 2007.)

8\) I certify that the federation named in this application prohibits
the sale or lease of CFC

contributor lists.

9\) I certify that the federation named in this application conducts
publicity and promotional

activities based upon its actual programs and operations, and that these
activities are truthful and non-deceptive, include all material facts,
and make no exaggerated or misleading claims.

10\) I certify that the federation named in this application effectively
uses the funds contributed

for its announced purposes.

11\) I certify that the federation named in this application does not
employ, in its CFC operations, the services of private consultants,
consulting firms, advertising agencies or similar business

organizations to perform the policy-making or decision-making functions
in the CFC.

12\) I certify that the federation named in this application prepares
and makes available to the

public an annual report that includes a full description of the
federation\'s activities and supporting services, member fees and/or
service charges, and identifies its directors/governing body and chief
administrative personnel. **Include as *ATTACHMENT F* a copy of the most
recently completed annual report.** *See Instructions Item 12 for
additional information.*

13\) I certify that the organization named in this application is in
compliance with all statutes,

Executive orders, and regulations restricting or prohibiting U.S.
persons from engaging in transactions and dealings with countries,
entities, or individuals subject to economic sanctions administered by
the U.S. Department of the Treasury's Office of Foreign Assets Control.
The organization named in this application is aware that a list of
countries subject to such sanctions, a list of Specially Designated
Nationals and Blocked Persons subject to such sanctions, and overviews
and guidelines for each such sanctions program can be found at
<http://www.treas.gov/ofac>. Should any change in circumstances
pertaining to this certification occur at any time, the organization
will notify OPM\'s Office of CFC Operations immediately

14\) **Include as *ATTACHMENT G* the 25-word statement for listing the
federation in the campaign charity list. Also include with *ATTACHMENT
G* a 25-word statement *for each member organization. See Instructions
Item 14 for additional information on the optional Taxonomy Codes.***

**[Certifying Official]{.smallcaps}**

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
am the duly appointed representative

> *(Print Name)*

of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
authorized to certify and affirm all statements

*(Print Federation certification)*

enclosed in this application. I certify that I have read all the
certifications set forth in this document and affirm their accuracy. In
addition, by checking the box next to the certification, the federation
named in this application acknowledges and agrees to comply with that
certification.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Signature)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Typed or Printed Name)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *(Title)*

Date Completed \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# 

**NOTE:**

**Applications will not be accepted if submitted electronically or by
facsimile.**

**The certifying official's signature in the federation application must
be original. Federations are permitted to provide photocopies of the
certifying official's signatures of its members if it has the original
on file. The LFCC reserves the right to request a copy of the original
signature. Automatic pens and/or signature stamps may not be used.**

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