TECHNICAL DATA CARD for CIMSA NATIONAL OFFICER CANDIDATE

1 Name (first/middle/last) _____________________________________________

2 Current Position in SCo _____________________________________________

3 Candidate for _________________________ Period ______________

4. Address ________________________________________________

________________________________________________

5. Phone ________________________________________________

6. Cell Phone ______________________________________________________

7. Fax ________________________________________________

8. Email ________________________________________________

9. Personal Homepage ________________________________________________

_____________________ _____________________ Date Signature

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