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DCED-CLGS-19-5 Report of Elected and Appointed O f f i c i a l s 04 075 5<br />

Additional Elected and Appointed Officials not Included in Pre -Printed Report:<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ___________________________________<br />

Address _______________________________________<br />

______________________________________________<br />

______________________________________________<br />

Telephone Number (______) ________ - ____________<br />

If Elected: Political Affiliation ____________________<br />

Year Term Ends ______________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ___________________________________<br />

Address _______________________________________<br />

______________________________________________<br />

______________________________________________<br />

Telephone Number (______) _______ - _____________<br />

If Elected: Political Affiliation ____________________<br />

Year Term Ends ______________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ___________________________________<br />

Address _______________________________________<br />

______________________________________________<br />

______________________________________________<br />

Telephone Number (______) _______ - _____________<br />

If Elected: Political Affiliation ____________________<br />

Year Term Ends ______________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ___________________________________<br />

Address _______________________________________<br />

______________________________________________<br />

______________________________________________<br />

Telephone Number (______) _______ - _____________<br />

If Elected: Political Affiliation ____________________<br />

Year Term Ends ______________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ___________________________________<br />

Address _______________________________________<br />

______________________________________________<br />

______________________________________________<br />

Telephone Number (______) _______ - _____________<br />

If Elected: Political Affiliation ____________________<br />

Year Term Ends ______________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ________________________________<br />

Address ____________________________________<br />

___________________________________________<br />

___________________________________________<br />

Telephone Number (______) _______ - __________<br />

If Elected: Political Affiliation _________________<br />

Year Term Ends ___________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ________________________________<br />

Address____________________________________<br />

___________________________________________<br />

___________________________________________<br />

Telephone Number (______) _______ - __________<br />

If Elected: Political Affiliation _________________<br />

Year Term Ends ___________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ________________________________<br />

Address ____________________________________<br />

___________________________________________<br />

___________________________________________<br />

Telephone Number (______) _______ - __________<br />

If Elected: Political Affiliation _________________<br />

Year Term Ends ___________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ________________________________<br />

Address ____________________________________<br />

___________________________________________<br />

___________________________________________<br />

Telephone Number (______) _______ - __________<br />

If Elected: Political Affiliation _________________<br />

Year Term Ends ___________________<br />

Elected and Appointed: Sex: M____F____<br />

T i t l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _<br />

Name ________________________________<br />

Address ____________________________________<br />

___________________________________________<br />

___________________________________________<br />

Telephone Number (______) _______ - __________<br />

If Elected: Political Affiliation _________________<br />

Year Term Ends ___________________<br />

Elected and Appointed: Sex: M____F____<br />

HAVE YOU COMPLETED ALL ITEMS?<br />

Signature of Township Secretary:<br />

________________________________________________<br />

Date Signed:<br />

_______________<br />

V-28

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