Date of Election

Assembly Location

Membership #    Last Name:    First Name:   Initial:    Council #

Address Change

Street:    City:    State:    Zip:

Membership #    Last Name:    First Name:   Initial:    Council #

Address Change

Street:    City:    State:    Zip:

Membership #    Last Name:    First Name:   Initial:    Council #

Address Change

Street:    City:    State:    Zip:

Membership #    Last Name:    First Name:   Initial:    Council #

Address Change

Street:    City:    State:    Zip:

Membership #    Last Name:    First Name:   Initial:    Council #

Address Change

Street:    City:    State:    Zip:

Membership #    Last Name:    First Name:   Initial:    Council #

Address Change

Street:    City:    State:    Zip:

Membership #    Last Name:    First Name:   Initial:    Council #

Address Change

Street:    City:    State:    Zip:

Membership #    Last Name:    First Name:   Initial:    Council #

Address Change

Street:    City:    State:    Zip:

Membership #    Last Name:    First Name:   Initial:    Council #

Membership #    Last Name:    First Name:   Initial:    Council #

Membership #    Last Name:    First Name:   Initial:    Council #

Membership #    Last Name:    First Name:   Initial:    Council #

Membership #    Last Name:    First Name:   Initial:    Council #

Assembly Meets:

Signed Faithful Comptroller:   Membership Number:

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