CHANGE OF NAME/ADDRESS-LOCAL LODGE 2052

Old Information

First Name Middle Initial

Last Name

New Information

First Name Middle Initial

Last Name

Street Address 1 

Street Address 2

City

State

Zip -

Phone Number Area Code  Phone Number -

Email Address

Please print this form and mail to:

John Goebel
307 S. Walnut St.
Mayville, WI 53050

or email the basic information to John Goebel or Bruce Wiese