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Chapter Name:______________________________________________

Officers:

President: ______________________________________________

Vice-President:__________________________________________

Secretary:______________________________________________

Treasurer:______________________________________________

State Delegate:___________________________________________

State Delegate:___________________________________________

Contact Name:______________________________________________

Address:________________________________________________

City/Zip Code:___________________________________________

Phone: _________________________________________________

E-Mail/Fax______________________________________________

Membership Meetings:

Usual Time:_____________________________________________

Usual Place:_____________________________________________

__________________________________________________

__________________________________________________

Dues:_______________________________________________

Activities:___________________________________________________

_______________________________________________________

_______________________________________________________

Anything else you would like to have known:_________________

_______________________________________________________

_______________________________________________________

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