OFFICIAL FORM DISTRICT: 6TH CHAPTER: NANCAMARINAN NAME STATUS MSP CATEGORY SIGNATURE (Surname, Given Name, Middle Name) re-census/ new active/inactive 1. Gailan, Justine E Re-Census Active 2. Limos, Marvin F. A Re-census Active 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Prepared by: Noted: Attested: ____________________ ____________________ ________________________ CK Chapter Secretary CK Chapter President CK Chapter Adviser Note: Kindly reproduce if necessary. Accomplish in two (2) copies legibly and in print.