Personal Information 

                Name:          

            Address:          

                 City:            

               State:            

          Zip Code:           

                Tele:           

             Mobile:           

              E-Mail:           

            Married:            Yes No

Spouse Information, if  married.

                Name:           

            Address:           

                  City:          

                State:          

          Zip Code:             

         Telephone:            

              Mobile:          

               E-Mail:          

              Children Info:  Names of Child/Children

Registration Fees: (Single $5:00, Married $10:00)

Dues can be paid monthly, half  yearly or yearly.
Additional information can be obtained from  Abass Bangura, President of SLCCO (614 397 5306) abangura@slccoonline.org
A copy of the form should be mailed to 3092 Ambarwent Road, Reynoldsburg OH, 43026.

Please submit the form by pressing the Submit Form button