I hereby give my permission to use the following information on the Columbia Kiwanis Club Web Site "members" page:

My Name:

My Organization Name:

My Position in the above organization:

My Work Phone Number:

My organization's website address (URL):

I have or will provide a copy of my business card that I would like displayed on the web site. Yes   No

My Home Phone Number:

My Address: Work  Home

My E-Mail address:

My Office or position in the Columbia Kiwanis Club:
Member  Senior Member Officer/Former Officer
Club Officer title:

You may send this form by email to the site Webmaster, Ed Tilden, by clicking on the "Submit by Email" button.

You may also print this form, sign and date it, and mail it to the club address shown above.

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