Directory Information Form

Local Number:

President:

    Name:

        Telephone:

                                        Work: Home: Cell:

    Fax:  E-Mail

    Address:

Vice President:

    Name:

        Telephone:

                                        Work: Home: Cell:

    Fax:  E-Mail

    Address:

Secretary:

    Name:

        Telephone:

                                        Work: Home: Cell:

    Fax:  E-Mail

    Address:

Treasurer:

    Name:

        Telephone:

                                        Work: Home: Cell:

    Fax:  E-Mail

    Address:

Insurance Administrator:

    Name:

        Telephone:

                                        Work: Home: Cell:

    Fax:  E-Mail

    Address: