State-DIR-MiscFam

KNIGHTS OF COLUMBUS ILLINOIS STATE COUNCIL

STATE DIRECTORY INFORMATION - DIR1
Use to Report Contact Information for State Officers, Directors, Chairmen, District Deputies, Special Appointments, etc.

This form is for use by State Family Members (Elected & Selected Officers, Chairmen, Directors, District Deputies, etc.) ONLY to report their contact information for the State Directory.

State Family Position Information

Name: *

Position (s) in State Council: *

Council #: *

Diocese: *

Membership #: *

Spouse (Print clearly as you want it to appear in Directory)

ADDRESS

Street Address: *

Apt., Lot, Unit or Condo #:

AND PO Box #: (State office needs BOTH addresses)

City: *

State *

Zip Code + 4: *

Phone and E-Mail Information

Home Phone # *

Business or Work # (with Extensions)

Cell #:

Fax #:

E-Mail Address: *

E-Mail Address:

What contact numbers you want to appear in the state directory? (Check All That applies) *

If you are mailing this form, please return it to:

Illinois State Council

PO Box 681 Kankakee, IL 60901-0681

A copy of this form will be sent to the address you entered above.