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| Name: | ________________________ | Spouse: | ___________________ |
| Address: | ________________________ | For your own distinctive Chapter 1000 nametag ($5.00): | |
| City, ST, Zip: | ________________________ | ||
| e-mail address: | ________________________ | Name as you want it to appear: | ___________________ |
| Home Phone: | ________________________ | ||
| Work Phone: | ________________________ | Project/Aircraft (optional): | ___________________ |
| EAA# (Required): | ________________________ | ||
| Aircraft Owned: | _____________________________________________________________ | ||
| Aircraft Projects | _____________________________________________________________ | ||
| and Interests: | _____________________________________________________________ | ||
| _____________________________________________________________ | |||
| Occupation: | _____________________________________________________________ | ||
| Aviation Accomplishments: | _____________________________________________________________ | ||
| How I found out about Chapter 1000: | _____________________________________________________________ | ||