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Public Statement of Sponsored Travel By Members

Name of Member:
Name of any person accompanying the Member (if any):
Destination(s):
Purpose of the trip:
Sponsor of trip (official name):

Dates (yyyy/mm/dd):

From:

To:

(

days)

I am including supporting documents for transportation and/or accommodation.

I was unable to obtain supporting documents for transportation and/or accommodation.

	Title
	Supporting Documents.pdf

Signature Date: 2012/09/25
Name: Dave Van Kesteren