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Member Questionnaire

Are you a commissioned Kentucky Colonel? Yes No

What was the approximate date of your commission

Do you have a current year membership card from the Honorable Order?
Yes No

Would you like information on how to reactivate your membership? Yes No

Membership # (if known)

Name

Address

City/State/Zip

Country

Is the address above a change from the one currently on file at the Honorable Order? Yes No

Email Address

Phone

Your birth date

Note: If you have a "winter" or alternate address, please complete the followwing fields.

Alternate Address

City/State/Zip

Country

Dates this address should be used

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