TECHNICAL DATA CARD for CIMSA

NATIONAL OFFICER CANDIDATE

1 Name (first/middle/last)

_____________________________________________

2 Current Position in SCo _____________________________________________

3 Candidate for

_________________________ Period ______________

4. Address

________________________________________________
________________________________________________

5. Phone

________________________________________________

6. Cell Phone

______________________________________________________

7. Fax

________________________________________________

8. Email

________________________________________________

9. Personal Homepage

________________________________________________

_____________________

_____________________

Date

Signature

Picture