Illinois State Council Form

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ILLINOIS STATE COUNCIL
2010-2011 DIRECTORY INFORMATION
**PLEASE PRINT OR TYPE**
READ THIS BEFORE YOU COMPLETE THIS FORM.
This information will appear in our State
Directory:
Please provide your COMPLETE address including: Directions (N, S, E, W), Avenue, Street, Drive, Lane etc. Be
sure to show your PO Box AND your HOUSE ADDRESS. The State Office needs BOTH addresses.
* FIELD MUST BE COMPLETED IF APPLICABLE
COUNCIL NAME____________________________________________COUNCIL#________________________________________
# * ___________
MEETING LOCATION ADDRESS *____________________________________________________ PO BOX
CITY__________________________________________________ZIP CODE +4 CODE (if known) ____________- ______________
MEETING LOCATION PHONE: (_______)____________________
FAX #(_____)_________________________
COUNCIL MEETS ON WHAT DAYS OF THE MONTH: (i.e. 2ND AND 4TH THUR, etc):__________________________________
COUNCIL WEB SITE :____________________________________________Email________________________________________
TYPE OF MEETING FACILITIES
CIRCLE ONE
A) MEETS AT CHURCH OR SCHOOL HALL-ON MEETING NIGHTS ONLY
A
B) CLUBROOM-BUILDING - RENTAL-OPEN MEETING NIGHTS ONLY
B
C) CLUBROOM-K OF C FACILITY-OPEN TO MEMBERS ONLY
C
D) CLUBROOM-K OF C FACILITY-OPEN TO PUBLIC
D
E) OTHER: ______________________________________________
E
IF THERE IS NO CHANGE IN GRAND KNIGHT FROM LAST YEAR’S DIRECTORY PLEASE CHECK BOX
2010-2011 GRAND KNIGHT
NAME_______________________________________________SPOUSE’S NAME_________________________________________
*
*
HOUSE ADDRESS
________________________________________ ____________________APT, UNIT, LOT #
_____________
*
AND PO BOX #
________CITY______________________________ZIP CODE +4 CODE (If known)____________ - ___________
*
PHONE:
(_______)_______________
BUSINESS (_______)_________________
FAX #(_____)__________________
E-MAIL ADDRESS _________________________________________
IF THERE IS NO CHANGE IN FINANCIAL SECRETARY SINCE LAST YEAR’S DIRECTORY PLEASE CHECK BOX
FINANCIAL SECRETARY
**AS APPOINTED BY SUPREME COUNCIL**
NAME______________________________________________SPOUSE’S NAME________________________________________
*
HOUSE ADDRESS
__________________________________________________ ______ APT, UNIT, LOT # *______________
*_
AND PO BOX #
_______CITY______________________________ZIP CODE + 4 CODE (if known) _____________ -_________
*
PHONE:
(_______) ___________________________________BUSINESS: (_______) ___________________________________
E-MAIL ADDRESS _____________________________________
FAX # (___) ______________________
C: EAST:\Forms/DIR 1

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