GROUP NUMBER  (OFFICE USE)

MEMBER ID #    (OFFICE USE)

PERSON CODE   (OFFICE USE)

REL. CODE  (OFFICE USE)

LAST NAME    (REQUIRED)

FIRST NAME     (REQUIRED)

MIDDLE INITIAL   (OPTIONAL)

GENDER  (REQUIRED)

BIRTHDATE (YYYYMMDD)  (OPTIONAL)

EFF. DATE (YYYYMMDD)  (OFFICE USE)

TERM. DATE (YYYYMMDD)  (OFFICE USE)

ADDRESS 1     (OPTIONAL)

ADD. 2 APT. #  (OPTIONAL)

CITY  (REQUIRED)

ST  (REQUIRED)

ZIP CODE (OPTIONAL)

PHONE  (OPTIONAL)

OFFICE USE

OFFICE USE

REQUESTOR'S NAME - FIRST INITIAL & LAST NAME (REQUIRED)

OFFICE USE

REQUESTOR'S ORG. - Abbreviate if needed.  (REQUIRED)

CARD REPRINT (OFFICE USE)

REQUESTOR'S PHONE NUMBER

RESERVED  (OFFICE USE)

LABEL CODE (OFFICE USE)

ALTMEMID  (OFFICE USE)

FILLER  (OFFICE USE)