559-229-8287
New
Membership or Renewal Application for 2012
Name ________________________________ Birthdate: Day ______ Mo ______ Yr __________
Maiden Name __________________________ Village(s) ________________________________
Spouse's Name _________________________ Birthdate: Day ________ Mo _____ Yr __________
Maiden Name _________________________ Villages
__________________________________
Anniversary
__________________________
Address_______________________________________ City ___________________ State ______
Zip Code ____________-_________ Phone
___________________________________
E-mail address:
______________________________________ Do you want the Newsletter sent
By e-mail? Yes ____ No ____
Youth/Student Name
___________________________________ Birth Date: ________________
Youth/Student Parents Name
_______________________________________________________
Name of person paying for Youth/Student
membership ___________________________________
Surnames you are researching
_______________________________________________________
Office Use: Date Paid ______________ Amt.
Pd ___________ Year(s) Paid For _____________
Renewal
_________ New _________ Category _________
Yearly Chapter Dues $15 ______Youth $8 ______Student $15______National
Dues $50 ______
"
Local and National Dues are to be sent to the local
chapter. International Life Membership: See chapter staff.
PR _____Cpr _____Dues Rem _____ML _____SML _____Cpem _____BD _____Anniv ______
" "
NL_____ New Mem Pkt _____ Front Cpr
ML _____ Ca CDC Report _____
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PLEASE
NOTE: Dues are due by
January 1 and delinquent by January 31.