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District 837-I.A.M.A.W.
Name: Address: Apt./Lot #: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Email: Employer: Employer Location/Address: Product/Service Rendered: Number of Employees: Number of Shifts: Other Comments: Lead Received by: Name: Address: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Email: Local Lodge: Lead Contacted: Date: By: Employee Contacted: Date: By: Working on Survey? Yes No (Use Reverse Side for Additional Comments) Please forward a copy to District 837, I.A.M.A.W., Attn: Mike Lloyd
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