Name: ___Tahira Lewis_______________________________________
Address: __28 Dellwood Dr. Fairborn, Oh 45324_______________________________________
_________________________________________________
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Phone number: __937-751-6914_______________________
Email address: _lewis.tahira@gmail.com__________________________________
Initial each of the following:
_TL_____ I have read and agree to abide by the Dayton Diode Charter.
__TL____ I have read and agree to abide by the Membership Agreement.
__TL____ I have signed the Liability Waiver.
Applicant Signature: ____Tahira Lewis _______________________________ Date: __4/11/2022__________
Officer Signature: _______________________________________ Date: ____________
Licensed under Attribution-Noncommercial-Share Alike 3.0 Unported based on the Hive 13 Membership Application
Consensed on by Dayton Diode membership on Nov 2, 2010.