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REQUEST TO MAINTAIN AN ADDITIONAL

CHAPTER OF THE ANARCHIC INSURGENCE

IN A NON-LOCAL AREA

 Please use this form if you are a member or non-member outside the central 

 service area wishing to establish your own local chapter of The Anarchic

 Insurgence. Complete it truthfully and to the best of your ability. If you have

questions about any of the material on this form, you may contact an officer by e-mailing us at one of the following two e-mail addresses:

1) 2. The.anarchic.insurgence@gmx.com

2) 3. The-anarchic-insurgence@myspace.com

 Please copy and paste the form in its entirety in an e-mail it to one of the abovetwo e-mail addresses, and then replace the blanks with your answers. Please note,

 you must be 18-years-old or older to start a chapter of the organization in your 

area. We apologize for the personal nature of some of the information needed, but 

it is strictly for the protection of the organization, its members and officers and its

mission. Thank you for your interest in expanding The Anarchic Insurgence!

PERSONAL INFORMATION.

 Please print.

What is your full name (last, first middle)?

 _______________________________ 

What is your home street address? _____________________________________ 

City: ______________________  

Zip Code: ______________________  State: ___________  

Age: ___________  

Birthdate: ______________________  

Gender: ______________________  

Eye Color: ______________________  Hair Color: ______________________  Height: ______ ft. _______ in.

Weight: _________ lbs.

Religion (optional): ______________________  

Political Views (optional ): ______________________  

Please list any tattoos you may currently have:

3) _________________________________________________________ 

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How long have you been employed there? ___________________________ 

If you were fired/laid off, or if you quit your job, when did this take place?

 __________________________ 

What is your job title? __________________________  

What are your job duties? ____________________________________________ 

 __________________________________________________________________  __________________________________________________________________ 

MISC. QUESTIONNAIRE.

 Please print.

Are you already a member of the organization? ___________________________ 

Do you have officers lined up to assist you? ___________________________ Do you have members ready to join? ___________________________ 

Are you prepared to follow the guidelines set forth by the organization?

 ___________________________ 

Thank you for completing this form and submitting it to The Anarchic Insurgence.

We will review it and respond with an answer as soon as we possibly can. Please

note, this form is subject to change, however, we will send notice to all members

and officers of any specific changes.