Last Name*    First Name* 
  Middle Initial 


Please provide the information to appear in the Grand Court Directory.


   Address 1    Address 2 


   City    State    Zipcode 


   Phone Number    Cell Phone 

   E-mail Address* 


   
Please indicate you acceptance or rejection of Grand Office and/or Committee(s) appointment.



   Grand Court Office    Are you accepting appointment to the Grand Office? 
  No
  Yes
  NA



   Committee 1    Are you accepting appointment to Committee 1? 
  No
  Yes
  NA



   Committee 2    Are you accepting appointment to Committee 2? 
  No
  Yes
  NA



   Committee 3    Are you accepting appointment to Committee 3 
  No
  Yes
  NA



   Committee 4    Are you accepting appointment to Committee 4 
  No
  Yes
  NA



   Committee 5    Are you accepting appointment to Committee 5 
  No
  Yes
  NA



   Will you be present at the Pasta Dinner (2/4/12) when the Grand Officers are announced? 
  No
  Yes
  NA



   Will you be at Grand Court for the installation of Grand Officers? 
  No
  Yes
  NA



Thank you for being a part of the 2012-2013 Grand Court Team.


Honored Lady Jullie Scanlon, Grand Associate Matron

Sir Knight Stephen Kellner, Grand Associate Patron