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TENTATIVE DATES: July 15 – 16, 2005, Nashville, TN. (For you) Good____ Bad____

NAME: _____________________________________________________

Contact Address: ______________________________________________ (Business) (home) ?

______________________________________________ Circle one.

State and Zip: _________________________________________________

Telephone: AC__________ Phone: ______________________________ (business) (home) ?

E-mail Address:________________________________

Affiliated with the CLGPGT Yes No If yes, Dominion_________________________

Names, places, relatives, other connections:

1.____________________________________________________ Relative_____ Other______

2.____________________________________________________ Relative_____ Other______

3.____________________________________________________ Relative_____ Other______

4.____________________________________________________ Relative_____ Other______

6.____________________________________________________ Relative_____ Other______

7.____________________________________________________ Relative_____ Other______

8.____________________________________________________ Relative_____ Other______

9.____________________________________________________ Relative_____ Other______

10.___________________________________________________ Relative_____ Other______

Do you have memorabilia, artifacts, funeral programs, or other historical materials? Yes___ No___

Please return this form before June 15, 2005 to:

Meharry Lewis, P.O. Box 830384, Tuskegee, AL 36083 (or FAX to 334 727-5204)