| Nomination Request |
| Name | ______________________________ |
| Address | _________________________________________________________ |
| Telephone | ___________________ |
| Originally From | ___________________ |
| Date / Place of Birth | _______________________ |
| Emigrated | __________ |
| Spouse | _______________________ |
| Children | ____________________________________________________________ |
| ____________________________________________________________ | |
| Father's Name | _______________________ |
| Mother's Name | _______________________ |
| Brothers & Sisters | ____________________________________________________________ |
| ____________________________________________________________ | |
| Notes | __________________________________________________________________________________ |
| __________________________________________________________________________________ | |
| __________________________________________________________________________________ |
Print, fill out, and mail this form to : Raymond Dib, 64-51 Fitchett ST, Rego Park, NY, 11374, USA
Please include a check payable to Raymond Dib, at a USA bank.Full Family Entry |
$ 200 USD |
Single Person Entry |
$ 100 USD |
Pictures |
$ 25 USD each |
|
Copyright © 1998-2007. Raymond Maurice K. H. Dib - New York. No reproduction is allowed without the expressed approval of the publisher. |
Raymond Maurice K. H. Dib