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Classmate Questionnaire

Please cut and paste this page to your word processor, complete all or as much of the form as 
you feel appropriate, then email to muirmustang1956@ix.netcom.com or snail mail a copy to: 
Eddie Moses Post Office Box 2009, Fullerton, California 92833.  All information will be kept confidential.

1.   Last Name (1956): 

2.   Last Name (2001): 

3.   First Name: 

4.   Nickname: 

5.   Middle Name: 

6.   Date of Birth: 

7.   Current Address and Street Name: 

8.   City: 

9.   State: 

10.  Zip Code: 

11.  Home Telephone Number: 

12.  Home Fax Number: 

13.  Cell Phone Number: 

14.  Work Phone Number: 

        Extension Number: 

15.  Work Fax Number: 

16.  Email

        Home Email Address: 

        Work Email Address: 

17.  Employer:

        Division of:

        Work Address:

        Job Title or Profession:

18.  Marital Status:

     (S = Single; M = Married; D = Divorced; W = Widow[er])  

19.  Graduated From:

        High School:

        Junior High School:

        Elementary School:

20.  Spouseís First Name:

        Nickname:

        Middle Name:

         Date of Birth:

21.  Name, address and telephone number of someone who would always know how to contact you:

22.  Any additional information you wish to provide, including your family or work history, achievements, children, or any information about the residence or work address of classmate from John Muir and/or your Junior High School:  (Feel free to send additional pages)

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