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• <br />Date Organized <br />Corporation Unincorporated Association <br />Religious <br />Organization <br />Veterans Organization <br />F1 (non-profit) Educational Organization Civic Organization <br />❑CharitableElVolunteer <br />Organization <br />Fire Company Fraternal Organization Other <br />❑ <br />FOR M.S.LC. USE ONLY <br />AUTHORIZED OFFICER OF ORGANIZATION SIGN BELOW <br />❑TAX FORM SENT <br />/ , <br />of S,nMme i... "'— �i ...Dale L.� <br />BY <br />Tltle..�'�(�(�(./.�C/ <br />DATE. <br />TELEPHONE AREA HOME PHONE <br />- NUMBERS <br />/f 1.,.ao�1 �og�3g1 �76a <br />DATE OF OCCASION ?-.'... .. . <br />V AREA BUSINESS TEL. NO. <br />NUMBER OF OCCASIONS E IS 3 a O 3 <br />NEXT TWELVE (12) MONTHS _... ................ <br />INV. ASSIGNED. <br />Assigned By <br />Dale <br />• <br />