Name *

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Last

Phone: *

Email *

Mailing Address *

Occupation and employer: *

What is your tie to the CHI Community? *

Which of your personal skills or strengths do you think would benefit CHI? *

Do you have a committee you’d like to serve on or a particular area of interest? *

The CHI Board of Directors meets monthly on the fourth Tuesday at 7 PM. Do you see any scheduling problem that might affect your attendance? *

• Yes
• No

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