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Name of Chapter:
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Date:
Information
Last Name
First Name
MI
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ST
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(O)
(Cellular/Other)
Email (Work)
Email (Home)
Parish
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Amount Collected $
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Information
Last Name
First Name
MI
Address
City
ST
Zip
Phone (H)
(O)
(Cellular/Other)
Email (Work)
Email (Home)
Parish
Membership Type
Amount Collected $
Paid National $
Paid Chapter Dues $
Information
Last Name
First Name
MI
Address
City
ST
Zip
Phone (H)
(O)
(Cellular/Other)
Email (Work)
Email (Home)
Parish
Membership Type
Amount Collected $
Paid National $
Paid Chapter Dues $
Name of Chapter:
Reporter Signature
Total Number of Members Reported:
Total Number of Youth Members Reported:
Total Number of New Members Reported:
Total $ Collected for individual membership:
Total $ Collected for family membership:
Total $ collected for retired membership:
Total $ collected for youth (under 21):
Total $ collected for life membership :
Total $ collected for sponsor (church):
Total $ collected for sponsor (organization):
Total $ collected for sponsor (associate):
Chapter yearly assessment
Totals collected for National:
Totals collected for Chapter:
Grand Total:
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