LAST NAME
FIRST NAME
M.I.
CITIZEN OF:
OCCUPATION
SPOUSE'S NAME
CITIZENSHIP
DEPENDENT CHILDREN (if any) - NAME(S) AGE, CITIZENSHIP, SCHOOL ATTENDED
LIMA HOME ADDRESS
PHONE
E-MAIL
BUSINESS ADDRESS:
COMPANY NAME
POSITION
E-MAIL
ADDRESS
PHONE(S)
FAX(ES)
NEWSLETTER TO BE SENT TO: OFFICE
PREVIOUS OVERSEAS POSTS:
COUNTRY - FROM - TO
EXPECTED LENGTH OF STAY IN LIMA
HOME TOWN, STATE/PROVINCE
CHURCH AFFILIATION (OPTIONAL)
BLOOD LISTING:
NAME
TYPE
NAME
TYPE
NOTE: Blood should not be donated if the prospective donor has ever had hepatitis, diabetes, malaria, Malta (Undulant) fever or venereal disease or has tested HIV Positive or is anemic.
PLEASE SELECT ACTIVITIES IN WHICH YOU ARE WILLING TO PARTICIPATE:
NEWSLETTER:
PICNICS:
WHAT OTHER ACTIVITIES ARE OF INTEREST TO YOU?
WHAT OTHER ORGANIZATIONS DO YOU BELONG TO IN LIMA?
WHAT ACTIVITIES CAN YOU SUGGEST FOR THE ASSOCIATION TO OFFER?
PLEASE TELL US A LITTLE ABOUT YOURSELF AND YOUR FAMILY:
YOU
YOUR SPOUSE
COLLEGE, YEAR GRADUATED
GRAD SCHOOL, SPECIALTY, YEAR
SPECIAL HONORS OR TITLES
ANY COMMENTS:
