Name:     
   
    Address:   
    
    Telephone:  
    
    Email:      
  
    AIM Screen Name:  

    Age Group:  
    13-17    18-21    22-29    30-39    40-49    50-59    60 & up
                                             
    
	Occupation:  

	Member Of CUMC?  Yes  No 

	Baptised?        Yes  No 
	
	Pledge Amount for 2002: