MR Chairman

KNIGHTS OF COLUMBUS ILLINOIS STATE COUNCIL

MARK YOUR CALENDAR

The 40^th Annual MR/LD Drive will be held on

SEPTEMBER 18 - 19 - 20, 2009

Council

* Council Name:

* Council #:

* Sender's Email Address

MR/LD Chairman

NOW is the time to submit your council chairman's name and start planning for the 2009 MR/LD Fund Drive.

Please complete this form EVEN IF THE CHAIRMAN IS THE SAME AS IN THE PAST YEARS. Return Form by August 1, 2009 so information packets are sent to the correct person.

* Chairman:

* Phone #:

* Street Address:

* City:

* State:

* ZIP Code:

(Include PO Box, APT, Unit Numbers if part of the Address)

Insurance Riders

Drive Dates covered under existing insurance.

Insurance riders are available if required for special dates are needed by another cooperating group. Provide the information as requested below. Be sure to indicate if they require special language.

Insurance Rider #1

Business Name:

Address:

* City:

ZIP:

Drive Date:

Insurance Rider #2

Business Name:

Address:

City:

ZIP:

Drive Date:

Insurance Rider #3

Business Name:

Address:

City:

ZIP:

Drive Date:

Insurance Rider #4

Business Name:

Address:

City:

ZIP:

Drive Date:

YOU MAY SUBMIT THIS FORM ELECTRONICALY OR MAIL THE FORM TO:

ILLINOIS KNIGHTS OF COLUMBUS

P.O. BOX 681

KANKAKEE, IL. 60901-0681

If your are submitting this form electronically, please remember to print a copy before submitting form.

* Indicates Response Required