State of North Carolina
  Knights of Columbus
     State Relocation Report

Council Name           Council Number

Council Contact Name

Phone   E-Mail

Name of Knight

Old Address

New address

Old Phone number- Home Cell

New Phone number Home Cell

Other info on the member Employer , emergency contact numbers, children:

Member Number Insurance Member   Yes      No

Wife’s name E-Mail Address

Send to: NC State Retention Chairman:      Vince Cerullo
                                                                 5070 Wood Run
                                                                 Mt Gilead, NC 27306
                                                                  vcerullo@embarqmail.com