Full Name:           Telephone:

Street:                 Email:

City:                  State: Zip Code:

Place of Birth: Name of Spouse:

Occupation:   

If your surname is NOT one of the recognized Setps of the Clan, please state your relationship to the Clan

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Children under 18 are also included in all Clan functions. Please indicate their names and year of birth:
    

Please state any talents or interests you wish to contribute:

Please type your full name (including middle name and academic initials, if you wish) precisely as you wish to have it engrossed on your membership certificate.

Would you be interested in serving as an elected officer of the Society?   Yes      No

Family members are included in all Clan functions. If a family member should wish to become a voting member ofthe Branch the fee is $10.00 for that privilege and a separate application should be completed.

Please give your membership number:
Life Member Number:
Or membership dues paid until (date):

Your membership will NOT become active until we receive payment. After 30 days unpaid memberships will be deleted
I understand and accept this policy: