* Denotes Required Input

Date*:

Title (Mr., Mrs.,etc.)*:

Name*:

Address*:

City*:

State*:

ZIP Code*: Plus 4:

Telephone Number (include area code)*:

Cell Phone Number (include area code):

Email*:

Local Camellia Club/Society:

I attended the below Judges' School

Judges' School*: Date*:

May we publish your information on the ACS Website - Members Only Access?

Yes

Name, City, State & ZIP Code Only

No

By submitting this form I do hereby make application to the Exhibition and Awards Committee of the American Camellia Society to have my judgeship renewed for five years from December 31. I certify that I am a member in good standing of the American Camellia Society. Further, I agree to abide by and comply with the rules, regula-tions, procedures and customs of the American Camellia Society governing flower shows in effect at thetime of the flower show being judged.