CENTRAL STATES ASSOCIATION OF SHRINE MOTOR CORPS

MID-WINTER MEETING

PRE-REGISTRATION FORM - I will attend
Please make sure I'm on the mailing list

Send this form to:

C.S.A.S.M.C.
Mr. Brad Waite - Secretary/Treasurer
926 South 41st Street
Omaha, NE 68105

FAX: (402) 346-9509

or send information in email to 
Bob Sides - (402) 421-4560  bob.sides@us.schneider-electric.com

C.S.A.S.M.C.  MEMBER or NON-Member
                                 (Circle, choose one)

My Name__________________________________

Unit Name__________________________________

Shriners (Temple)____________________________

C.S.A.S.M.C. Voting Rep._____________________

Address_____________________

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Telephone____________________

email address_________________