FIRST NAME 

LAST NAME

STREET ADDRESS

CITY    STATE PA NJ     ZIP CODE

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WIFE'S FIRST NAME         E-MAIL ADDRESS

DATE OF BIRTH

PROFESSION

ARE YOU INTERESTED IN HOLDING AN OFFICERS POSITION

IF SO WHAT POSITION

PLEASE INDICATE THE COMMITTEES THAT YOU WISH TO SERVE ON

 MEMBERSHIP               YES SELECT ONE NO            FLEA MARKET             YES SELECT ONE NO          CHICKEN BAR-B-QUE  YES SELECT ONE NO           

 FUNDRAISING             YES SELECT ONE NO            SUNSHINE                     YES SELECT ONE NO          ARC                                 YES SELECT ONE NO          

 GOLF OUTING             YES SELECT ONE NO            COAL BOOKS               YES NO SELECT ONE           PRO-LIFE                       YES NO SELECT ONE       

FOOTBALL TICKETS   YES NO SELECT ONE            SCRAPBOOK                 YES NO SELECT ONE          180 TICKETS                  YES NO SELECT ONE

DEGREE TEAM              YES NO SELECT ONE            CHARITABLE WORKS YES NO SELECT ONE          YOUTH                            YES NO SELECT ONE             

 CHRISTMAS PARTY/PICNIC    YES NO SELECT ONE

IS THERE ANYTHING THAT YOU WOULD LIKE TO SEE CHANGED IN THE COUNCIL?  YES NO SELECT ONE

IF YES PLEASE SPECIFY AND COMMENT. ALL SUGGESTIONS AND COMMENTS ARE TAKEN AS FOR THE GOOD OF THE ORDER AND KEPT CONFIDENTIAL. THE GOAL OF THIS QUESTION IS TO STRIVE FOR CONSTANT IMPROVEMENT AND TO MAKE OUR COUNCIL BETTER FOR ALL BROTHERS.