KYSAFF Membership Form



Please complete this application and mail it with payment to:

Kentucky Self-Advocates For Freedom, Inc.
PO Box 23555
Lexington, KY 40523-3555 USA

 

Chapter Name Membership List for

  

 

President:

  Vice-President:

Secretary:

     Treasurer:   

Please make copies of this page and fill in the following information for each member of your chapter.

 

Offices information

 

President:

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

 

Vice President:

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

 

Secretary:

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

 

Treasurer:

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

Members following information

Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

 

Name::

  Birth Date: :

Address::

  

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Name::

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Name::

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Name::

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.Name::

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 Home Telephone:

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E-Mail Address: 

    

 

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E-Mail Address: 

    

 

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E-Mail Address: 

    

 

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E-Mail Address: 

    

 

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Address::

  

 Home Telephone:

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E-Mail Address: 

    

 

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  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

 

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  Birth Date: :

Address::

  

 Home Telephone:

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E-Mail Address: 

    

 

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Address::

  

 Home Telephone:

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E-Mail Address: 

    

 

Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

 

Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

 

Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

 

Name::

  Birth Date: :

Address::

  

 Home Telephone:

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E-Mail Address: 

    

 

 

Author information goes here.
Copyright © 2003 [Kentucky Self-Advocates for Freedom, Inc.]. All rights reserved.
Revised: 07/23/08