Date of Joining ___________________  # of Years _____ 

EMAIL OR MAIL 2 (TWO) COPIES BY JUNE 1, 2012 TO:

Marcele Roahrig

5609 Oldwynne  Road

Hilliard  OH  43026-9507

mroahrig@columbus.rr.com

June 1, 2011   to  May 31, 2012

County ___________________  City or Town ________________________

Circle Name __________________________________________________

Date Organized _______________________________________________

Membership (International Order, Ohio Branch and Local Dues paid)

Senior Members _________  Junior Members  ( ages 0 – 18 ) ___________ 

New Members _____ Decrease _____  Withdrawals _____  Deceased _____

Pledges or money raised:

International Order:

     North American Indians . .   $ __________     Literacy . . . . . .  $ __________

     Around The World . . . . . .   $ __________     Autism . . . . . . .  $ __________

     Health Careers Scholarship $ __________    Student Ministry  $ __________

Ohio Branch:

     Maplecrest Pledge . . . . . . . . . . . . . .  $ __________

     Chautauqua Scholarship . . . . . . . . .  $ __________

     Memory Pearls . . . Number _____ . . $ __________

       _______________________________________

       _______________________________________

Do you include in your regular meetings:

Planned Bible Study __Y__N__ Give Source _________________________

Meditations ____Y___N______  Give Source _________________________

International Order Prayer ___Y___N___ Other _______________________

Please Fill In All Blanks.  If nothing was done or given, please indicate with a –0-

Circle President 

(for next year if known, otherwise current president)

Name __________________________________ Phone # _________________

Address _________________________________________________________

City ________________________ State ______________ ZIP ______________

Email Address ____________________________________________________

                               ( President or other responsible Circle representative)

International Order Projects supported at home and abroad, not listed above.

___________________________      _____________________________

___________________________      _____________________________

___________________________      _____________________________

Local Projects maintained and supported  by your circle.

___________________________      _____________________________

___________________________      _____________________________

___________________________      _____________________________

___________________________      _____________________________

CITATION REQUEST FORM: . . . . . . . . . . . . . DEADLINE   JUNE 1

NOTE: Include member’s last name (maiden) when they joined circle 

Circle Name _____________________________

                Date of Joining International Order ___________________ 

MEMBER CITATIONS

25 Year Members:

 Name and Address _______________________________________    

 Name and Address _______________________________________    

 Name and Address _______________________________________    

40 Year Members:

 Name and Address _______________________________________    

 Name and Address _______________________________________    

 Name and Address _______________________________________    

50-60-70-80 Year Members:

 Name and Address _______________________________________   

        Date of Joining ___________________  # of Years _____

 Name and Address _______________________________________  

        Date of Joining ___________________  # of Years _____

 Name and Address _______________________________________