TelecomPioneers
Maryland Chapter 44

Date:___________

Name_______________________________________________________________

Spouse or Significant Other______________________________________________

Home Address_______________________________________________________

City__________________________ State__________ Zip_________________

Home Tel # ( ) - __ __ __ - __ __ __ __ Bus. Tel # ( ) - __ __ __ - __ __ __ __

Work Address_______________________________________________________

Work Department & Title______________________________________________

Fax # ( ) - __ __ __ - __ __ __ __ On Lotus Notes ? Yes _____ No _____

Service Date______________ Birth Date: Mo__Day__Year____

INTERESTS

____ Environmental Projects

____ Verizon Reads (Reading To Elementary School Age Children
(Area)__________________________________

____ Painting Maps Of The United States On Elementary
School Playgrounds (Area)______________________________

____ Sewing Projects (Hug-A-Bears, Hug-A-Hearts, Bean Bags,
Holiday Stockings)

____ Planning Social Affairs

____ Holding Office

____ Pen Pal For A Child

Do You Have A Specific Talent You Would Like To Share? ______________________

Please mail completed form to:

Pioneer Office, Room G8, 99 Shawan Rd., Cockeysville Md.