| Newsletter |
Would you like to receive our Newsletter via postal mail?
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| Salutation |
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| First Name |
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| Middle/Maiden/Previous |
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| Last Name |
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| Address 1 |
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| Address 2 |
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| City |
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| State |
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| Zip Code |
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| Phone |
Your primary contact number
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| Email |
This is the email address we will use to send the Newsletter, if you chose to receive it by email.
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| Code |
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| Work Code # |
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| State Membership |
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| Status |
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| Date of Birth |
mm/dd/yyyy
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| Date of Death |
mm/dd/yyyy
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| Name/Location of Company Worked |
Where did Rosie work?
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| Dates of Work |
When did Rosie work?
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| Type of Work |
What work did Rosie do?
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| Rosie Name if Rb or Rv |
If new member is a RB or RI what is the Rosies Name and Relationship
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