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ADDITION / DELETION FORM <br />To: N C State Firemen's Association <br />P.O. Box 188 <br />Farmville, North Carolina 27828 <br />From: Orange County Fire Marshal's Office <br />Fire Department <br />P.O. Box 8181 <br />Address <br />Hillsborough, NC 27278 <br />ADDITIONS: <br />Paul(cr3,ncsfa.com or Melissa@ncsfa.com <br />Telephone (252) 75.3 -2626 <br />Toll Free 1 -800- 253- 473.3 <br />Fax (252) 75.3- 3.335 <br />Please add the name of David S. Merritt to our roster as a New Member for the year 2006 <br />David S. Merritt <br />Neu— <br />Chapel Hill, NC 27516 <br />Address <br />Mal )/ Female <br />DELETIONS: <br />G d Single <br />Please delete the name and information of <br />no longer a department member, <br />Effective Date: June 1, 2006 <br />Chief Mike Tapp - Fire Marshal <br />Orange County - P.O. Box 8181 <br />Hillsboroughi NO 27278 <br />Address <br />County Orange <br />Social Security Number DOB <br />Phone Number <br />smerritt@co.orange.nc.us <br />E -mail Address <br />Paid Volunteer /Retired Certified (Yes No) <br />Wagner, Jr. from our roster, as this person is <br />You may add one member for each member deleted at no charge. There is a membership fee of $12.00 for all <br />other members added. You have 30 days to send in membership dues if you fax this information in. It is <br />understood that no claims will be paid against this New Member until membership dues are received in our <br />office. After 30 days, if no membership dues are received, this New Member will not be covered. <br />Department may duplicate this form. <br />Effective January I, 2004 <br />