Metroplex Hungarian Directory

Proxy

*Name: __________________________________________________________

First name Last Name

Occupation:__________________________________

*Address: ____________________________________

Street

_______________________________________ _____________________________________________________

Town State ZIP

Phone: (____)________________________ e-mail: ____________________

I hereby gave my permission to the Metroplex Hungarian Cultural Circle to print

the above listed information from me in the “Metroplex Hungarian Directory”.

This proxy is effective indicated below.

Date:_____________________ ___________________________________

Print Name

_________________________

Signature

*Mandatory

Please fill out only those information from above what you wish to be listed in the Directory.

Mail this page to MHCC, 1404 Geneva Ln Plano, TX 75075 by November 15. 2001.

If you have any questions please feel free to call us or e-mail: magyarszo@hotmail.com