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<br />   			Name:  	,    .       --  .
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<br />   			Mailing  Address:   .--   -	.     ...,.  		_
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<br />   			Tel ephone:    , ,,,='; --  :,,\ '') -..;-•  j-     Home       					Business
<br />   			Ethnic  Background:    Black       	Indian      	White    , 	Other
<br />    																		—
<br />   			Sex:    Male    		Female   ,    			Age:     -1-
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<br />       					____
<br />   			Education:  (Highest)	/1/,, ...„ ,(, ,
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<br />   			Occupation:  	c..., ,. -.:',.„..._,_     ...     ,"...   			,   '    	_  ,
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<br />   			Community  Interests  and  Activities:   „:7.    .r..L„, '..-&,,_._   ,,,,., ,',      T/       ,
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<br />    														L.__ ,— 	i e 42.-C; di CA t  2   ex-49 nr,trl
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<br />      			In  which township do  you  reside?  (//, //.:/--  if,,,-; ,,   . c   '     ---
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<br />    			I  am  interested  in  serving  on:     .- /-. .. , / - .-
<br />    			___     												—
<br />     			Date:   „„(.._
<br />      											Signature  :	,.
<br />  															....
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