| Name: __________________________________ |
|
| Address: ________________________________ |
| _______________________________________ |
| City:________________________, State:_______ |
| ZIP:____________ |
| Spouse:_________________________________ |
| Phone:(_____)-_____-________ ext:________ |
| Years on Semmes:19____ To: 19____ |
| Rank:___________________________________ |
| email:___________________________________ |