(NOTE: Please print this form, then fill in only the blanks that are authorized to disclose.
Return form to: Harvey Scarborough, 411 Brownwood Cir., Ringgold, GA 30736)

I hereby authorize the Chattanooga Civil War Round Table to display on the www.chattanoogacwrt.org website my personal information as shown below:

   NAME: _________________________________________________________________________

   STREET ADDRESS: _______________________________________________________________

   CITY, STATE, ZIP: _____________________________________________________________

   MAILING ADDRESS: (if different from above): ___________________________________

   _______________________________________________________________________________

   HOME PHONE: __________________________ CELL PHONE: ____________________________

   EMAIL ADDRESS: _______________________  FAX NUMBER: ___________________________

   SPECIFIC INTEREST(S) IN THE CIVIL WAR: ________________________________________

   _______________________________________________________________________________

   OTHER INFORMATION: ____________________________________________________________

   _______________________________________________________________________________

   _______________________________________________________________________________


   I will not hold the Chattanooga Civil War Round Table (CCWRT) or the CCWRT 
   Webmaster responsible for any consequences, adverse or otherwise, that may 
   result from the disclosure of the above information on the Internet. I realize 
   that information, once made available on the Internet, even though for a short 
   period of time, may be retained and used by other sources after it is no longer 
   viewable on the CCWRT's website. Disclosure of the above information is solely 
   at the discretion of the CCWRT Webmaster.


   DATE: _____________________  SIGNATURE: _______________________________________

   This authorization shall be revoked on the following date: ____________________,

   or upon the following condition: ______________________________________________.

   Otherwise, please notify the CCWRT Webmaster Harvey Scarborough-SCARHDKJ@AOL.COM 
   to revoke this authorization.