NAME:_________________________________________________________________

                            HOME PHONE:_________________WORK PHONE:___________________

                            ADDRESS:______________________________________________________________

                            CITY:__________________    STATE:__________     ZIP CODE:_____________

                            OCCUPATION:_________________________________________________________

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                            DATE OF BIRTH:____________________________

                            YOUR ITALIAN HERITAGE:______________________________________________

                            PLEASE CHECK ACTIVITIES THAT MIGHT INTEREST YOU:

                                    LAGOON DAY:______MOTHER’S DAY TEA:______ CIVICS:______

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