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Box 22 SHAPE \* MERGEFORMAT  Tucker, GA 30085-0022 CALIFORNIA SQUARE DANCE COUNCIL FEDERATION OR ASSOCIATION CLUB LISTING FROM: NORTHERN CALIFORNIA SQUARE DANCERS ASSOCIATION Insurance Chairman: Peggy Rose and Ethlyn  Babe Sandau Mailing Address: PO Box 1117 City, State, & Zip: Brentwood, CA 94513 Telephone: (925) 240-1117 Club Name:  FORMTEXT       Mailing Address:  FORMTEXT       City, State, & Zip:  FORMTEXT       Number of Members:  FORMTEXT       Facility Being Used:  FORMTEXT       Rooms being used: Main Room  FORMTEXT       Kitchen  FORMTEXT       Bathrooms  FORMTEXT       Other  FORMTEXT       Street Address:  FORMTEXT       City, State, & Zip:  FORMTEXT       Date of Function:  FORMTEXT       Year:  FORMTEXT       Name of Additional Insured:  FORMTEXT       Street Address:  FORMTEXT       City, State, & Zip:  FORMTEXT        FORMCHECKBOX  ENDORSEMENT REQUIRED Facility Being Used:  FORMTEXT       Rooms being used: Main Room  FORMTEXT       Kitchen  FORMTEXT       Bathrooms  FORMTEXT       Other  FORMTEXT   Xdfz|~  ĴĂxl^x^H:^lj2hHGKOJQJU^J*jhHGKCJOJQJU^JmHnHujhHGKOJQJU^JhHGKCJOJQJ^JhHGKOJQJ^J3jhMhM5OJQJU^JaJmHnHu.jhMhM5OJQJU^JaJhMhM5OJQJ^JaJ(jhMhM5OJQJU^JaJhHGKCJOJQJ^JhHGK5CJOJQJ^JhHGK5CJOJQJ^J   V   D  |^`| |^`| @&^` $ a$$@&a$ $ @&a$$  ^`a$ d9   d9 23 3    : X $ B D \ ^ r ɼwkwkwk_wQGh~#OJQJ^Jjh~#OJQJU^JhHGKCJOJQJ^JhMCJOJQJ^JhHGKCJOJQJ^JhVCJOJQJ^JaJhMCJOJQJ^JaJhHGKCJOJQJ^JaJhMhHGKOJQJ^JaJhM5OJQJ^JaJhHGK5CJOJQJ^JhHGK0J5CJOJQJ^JhHGK5CJOJQJ^JhHGK0JCJOJQJ^JD F " p 8Nj @ lWD^l`gd@a  O @ lWD^l`gd6' @ lWD^l`gdv&dP  /! F$dN |^`| r t v      " H J ^ ` ݿtctYE'jh~#h~#OJQJU^Jh~#OJQJ^J!jjhHGKOJQJU^J&jhHGKOJQJU^JmHnHu!jhHGKOJQJU^JjhHGKOJQJU^JhHGKCJOJQJ^JhHGKCJOJQJ^JhHGKOJQJ^J&jh~#OJQJU^JmHnHujh~#OJQJU^J'jh~#h~#OJQJU^J` b l n p   ( ǻӜ~p_Q?Q#jh6'CJOJQJU^JaJh6'CJOJQJ^JaJ hvh6'CJOJQJ^JaJhvCJOJQJ^JaJhvOJQJ^J&jhHGKOJQJU^JmHnHu!jhHGKOJQJU^JjhHGKOJQJU^JhHGKCJOJQJ^JhHGKCJOJQJ^JhHGKOJQJ^J&jh~#OJQJU^JmHnHujh~#OJQJU^J( * , 6 8 J L ` b d n p սկկսկկսկկgս]QhHGKCJOJQJ^Jh6'OJQJ^J/j&h~#h6'CJOJQJU^JaJ/jh~#h6'CJOJQJU^JaJ/j:h~#h6'CJOJQJU^JaJh6'CJOJQJ^JaJ.jh6'CJOJQJU^JaJmHnHu#jh6'CJOJQJU^JaJ/jh~#h6'CJOJQJU^JaJ  ",.6^`bvxz歡ܐܡt^H*jh~#CJOJQJU^JmHnHu+j h~#h~#CJOJQJU^Jh~#CJOJQJ^Jjh~#CJOJQJU^J!jh hHGKOJQJU^JhHGKCJOJQJ^Jh~#OJQJ^J&jhHGKOJQJU^JmHnHu!jhHGKOJQJU^JhHGKOJQJ^JjhHGKOJQJU^JhHGKCJOJQJ^J024>@LNP̶ؠؔ{ocSG4S%j hHGKOJQJU^JaJhHGKOJQJ^JaJjhHGKOJQJU^JaJhHGKCJOJQJ^JhHGKCJOJQJ^JhHGKOJQJ^JhvhHGKCJOJQJ^JhP)CJOJQJ^J*jhM,CJOJQJU^JmHnHu+jh hM,hM,CJOJQJU^JhM,CJOJQJ^JjhM,CJOJQJU^JhvCJOJQJ^JhC}CJOJQJ^JNPH ,T,,,h-j-zmzm   d @ lWD^l`gd6' @ ldWD^l`gdv @ &dP @ l&dPWD^l`gdv @ lWD^l`gdv     "68FJLhjl´´tc´R!j hHGKOJQJU^J!jhHGKOJQJU^J!j^hHGKOJQJU^J&jhHGKOJQJU^JmHnHu!j hHGKOJQJU^JhHGKOJQJ^JjhHGKOJQJU^JhHGKCJOJQJ^JhHGKCJOJQJ^JjhHGKOJQJU^JaJ*jhHGKOJQJU^JaJmHnHu 68LNPZ\np,,,ϟϟoϟWϟUU/jh~#h6'CJOJQJU^JaJ/jlh~#h6'CJOJQJU^JaJ/jh~#h6'CJOJQJU^JaJ.jh6'CJOJQJU^JaJmHnHu/jh~#h6'CJOJQJU^JaJ#jh6'CJOJQJU^JaJh6'CJOJQJ^JaJ hvh6'CJOJQJ^JaJ    Street Address:  FORMTEXT       City, State, & Zip:  FORMTEXT       Date of Function:  FORMTEXT       Year:  FORMTEXT       Name of Additional Insured:  FORMTEXT       Street Address:  FORMTEXT       City, State, & Zip:  FORMTEXT        FORMCHECKBOX  ENDORSEMENT REQUIRED Facility Being Used:  FORMTEXT       Rooms being used: Main Room  FORMTEXT       Kitchen  FORMTEXT       Bathrooms  FORMTEXT       Other  FORMTEXT       Street Address:  FORMTEXT       City, State, & Zip:  FORMTEXT       Date of Function:  FORMTEXT       Year:  FORMTEXT       Name of Additional Insured:  FORMTEXT       Street Address:  FORMTEXT       City, State, & Zip:  FORMTEXT        FORMCHECKBOX  ENDORSEMENT REQUIRED     August 2011 , ,*,,,.,B,D,F,P,R,T,z,|,~,,,,,,,,,,,,,ƵСƐСƄxhxRh+jDh~#h6'CJOJQJU^Jjh6'CJOJQJU^Jh6'CJOJQJ^Jh6'CJOJQJ^J!jhHGKOJQJU^J&jhHGKOJQJU^JmHnHu!jXhHGKOJQJU^JhHGKOJQJ^JjhHGKOJQJU^JhHGKCJOJQJ^JhHGKCJOJQJ^Jh6'OJQJ^J,,,4-6-J-L-N-X-Z-f-h-------------...θΩyhTyyC!jhHGKOJQJU^J&jhHGKOJQJU^JmHnHu!jphHGKOJQJU^JhHGKOJQJ^JjhHGKOJQJU^JhHGKCJOJQJ^JhHGKCJOJQJ^Jhvh6'CJOJQJ^J+jh6'h6'CJOJQJU^Jh6'CJOJQJ^Jjh6'CJOJQJU^J*jh6'CJOJQJU^JmHnHuj--.b../$0l0001}f\}    @ lWD^l`gdv @ lWD^l`gd6' @ ldWD^l`gdv @ d&dP" @ ld&dPWD^l`gdv @ ldWD^l`gdv ....8.:.<.P.R.T.^.`.d.f...........///,/N/P/ȼԫԚȼԉ}l^L#jh6'CJOJQJU^JaJh6'CJOJQJ^JaJ hvh6'CJOJQJ^JaJhHGKOJQJ^JaJ!jFhHGKOJQJU^J!jhHGKOJQJU^J!j\hHGKOJQJU^JhHGKCJOJQJ^JhHGKCJOJQJ^JhHGKOJQJ^JjhHGKOJQJU^J&jhHGKOJQJU^JmHnHuP/d/f/h/r/t/////////////////0000 0$0B0ȰȰȰhȰ^RhHGKCJOJQJ^Jh6'OJQJ^J/jh~#h6'CJOJQJU^JaJ/jh~#h6'CJOJQJU^JaJ/j2h~#h6'CJOJQJU^JaJ.jh6'CJOJQJU^JaJmHnHu#jh6'CJOJQJU^JaJ/jh~#h6'CJOJQJU^JaJh6'CJOJQJ^JaJB0D0F0Z0\0^0h0j0l000000000000000011L1N1ܫܚ܎r\rFrr*jh6'CJOJQJU^JmHnHu+jh~#h6'CJOJQJU^Jjh6'CJOJQJU^Jh6'CJOJQJ^Jh6'CJOJQJ^J!j hHGKOJQJU^JhHGKCJOJQJ^J&jhHGKOJQJU^JmHnHu!jhHGKOJQJU^JhHGKOJQJ^JjhHGKOJQJU^JhHGKCJOJQJ^JN1b1d1f1p1r1~11111111112222θubL>4hHGKOJQJ^JjhHGKOJQJU^J*jhHGKOJQJU^JaJmHnHu%jhHGKOJQJU^JaJhHGKOJQJ^JaJjhHGKOJQJU^JaJhHGKCJOJQJ^JhHGKCJOJQJ^Jhvh6'CJOJQJ^J*jh6'CJOJQJU^JmHnHujh6'CJOJQJU^J+j hM,h6'CJOJQJU^Jh6'CJOJQJ^J111*2z22222222222233 @ d&dP" @ ld&dPWD^l`gdv @ ldWD^l`gdv   d^ `222&2(2*2P2R2T2h2j2l2v2x2z2|2~2222222222222222222222¶™••zvrzvrzvrzvrjbjhVCJaJhMCJaJhVhTjhTUjhHGKUjhHGKUhHGK!jhHGKOJQJU^JhHGKCJOJQJ^JhHGKCJOJQJ^JhHGKOJQJ^J&jhHGKOJQJU^JmHnHujhHGKOJQJU^J!j.hHGKOJQJU^J%2233 3hHGKhVhM3333 3 3 @ d&dP.:p~#/ =!"#$C% 2DText32MM/dd/yy-Date form filled in. 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