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1. Are you a temp or full charter chapter? (Required.)

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2. Roadname of person reporting (Required.)

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3. This report must be a submitted by a member of the chapter or state executive board or your CDO if a temp charter. What position do you serve in? (Required.)

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4. Reporting party Chapter Name (Required.)

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5. Reporting party State or Country (if outside the US) (Required.)

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6. Are you reporting a loss, accident, illness, or other qualifying event? (If this is a memorial addition request for a former member, that request requires unanimous approval of the state board, and that request must be sent via email to legacyrun@BACAworld.org by the state president.) (Required.)

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7. What is the legal & roadname of the person you are reporting about? (Required.)

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8. If a loss, date of loss

Date

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9. What Chapter are they in? (Required.)

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10. What State or Country? (Required.)

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11. Is Financial Assistance Needed? (Required.)

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