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This form is sent to our personnel officer in Division 12 for routing to the proper Flotilla in Your area.

Please provide the following contact information:

First Name
Last Name
Middle Initial
Street Address
City
State/Province
Zip/Postal Code
Home Phone
E-mail
Webmaster 070-12
Copyright © 2003 [USCG Auxiliary 070-12]. All rights reserved.
Revised: 02/24/08