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DOB

Emergency Contact Name

Emeregency Contact Phone

Occupation

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Exempt on Dues?

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Total Dues Paid:

Amount Past Due

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Date Constituted

Elevated Date

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Cap/Crown Size

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Petition Signer #1

Petition Signer #2

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SP College Year 1

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SP College Year 3

Petition Date

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Demit In

Transfered In

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Demit To Other Consistory

Demitted Out Date

Elected Date

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Date Healed

Suspended Date

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Expelled Date

Expelled Reason

Deceased Date Reported

Deceased Date Exact

Reinstated Date

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General Member USC Dues Paid Date

General Member USC Dues Paid Amount ($50)

Executive Member USC Dues Paid Date

Executive Member USC Dues Amount ($75)

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Member Office(s)

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Secretary/KSA Notes (Viewable to member)