APPLICATION FOR US DOMAIN STATUS

The following information needs to be sent to the ANC: Chapters, RC, and RST of your region. These contacts are available at the USNC Contacts page. The regional officers may have delegated their duty to an Assistant.

Proposed Domain Name:
Region:

Includes Chapters:
(list any chapters that make up the proposed domain; include whether they will be folded into the domain – not exist after the domain is formed; include chapter code and chapter name)

Proposed DC Name:
Proposed DC Cam #:
Proposed DC Email address:

Proposed ADC:
Proposed ADC Cam #:
Proposed ADC Email address:
(repeat as necessary)

Proposed Domain's physical mailing address (for contact purposes):

Proposed Domain's borders:
(Examples include "Tacoma city limits," or "Pierce County borders." If your proposed domain is adjacent to other Camarilla chapters or domains, please be more detailed.)

List each member's Name & Cam #
(15 paid members if within 30 miles of the next nearest Domain; 10 paid members if more than that; this requirement can be waived with favorable RC recommendation)

Describe a charity event held in the last 6 months:

Describe a social event held in the last 6 months:

Comments: