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Date__________________

Name________________________(Maiden)______________Class of

Address________________________ City_______________ST______Zip

Phone________________________________E-Mail

Spouse Name___________________________________Number of Children

Current Employer____________________Spouse Employer

Your Position________________________Spouse Position

Other information you would like to share:

Please mail this form in the enclosed envelope to:

St. Mary's Development, 301 E Adams St, ONeill, NE 68763