CLUB GRIEVANCE FORM

      Date of Incident:  ____/____/____          Time of Incident: ___________am or pm

      Nature of Grievance (please write legibly):

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      Complainant Name:  _______________________________________                Dated: ___/___/___

      Complainant  Signature: ____________________________________

      Witness Name:    __________________________________________              Dated: ___/___/___

      Witness Signature:   ________________________________________

       Date Received by Charter Membership:  ___/___/___

       Reprimand:       ___ Verbal            ___ Written           None  ____

      Recorded by Secretary :   ____/____/____