In Service to the Children of Dubuque

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First, Last Name*

Nickname

Home Address*

Phone*

E-mail Address*

Business Name

Your Position Title

Are you a former Kiwanian?

If so, which club?

Who is your Kiwanis sponsor?

Month and Date of your Birthday

Spouse's Name

Anniversary Date

What are your hobbies?

What do you see as the most important community need right now?

Date

Signature

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