OA Troop Representative

Date:__________________________

Name:_______________________________  Troop #:_________

Address:_____________________________ 

City:_____________________      State:___________________    

Zip code:___________________

Ordeal/Brotherhood/Vigil:_____________________________  

District :_________________________

Phone:__________________________    E-mail:________________________________

Scouting Experience:______________________________________________________

________________________________________________________________________

________________________________________________________________________

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OA Experience:__________________________________________________________

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Please Return Completed Form To:  

Stephen Pavlock
611 Wheeling Ave.
Glen Dale, WV 26038