Membership Application

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Please provide the name of the chapter and the city it is located in.
Provide the name of the President of the last chapter you were a member of.
Provide either a Phone number or email address for the President of the last chapter where you were a member.
Give the name of someone from your previous chapter than can provide a reference for you.
Phone Number and/or Email of Reference
Please describe in as much or as little detail as you like, the reason(s) you became inactive
Place a name and relationship on separate lines. ex. Bro. John Doe - colleague