Newsletter |
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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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Comments |
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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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