New membership Application

 

Name:                                                                                         

 

First name:                                                                                  

 

Address:                                                                                  

 

City:                                                         State:                              Postal code:                 

 

Telephone number:                                                   

 

Email:                                                                                                                                 

 

I authorize Association des Familles Messier to publish my email address:

                                                                          Yes______ No _______

 

Date of birth:                                                                                           

 

Place of birth:                                                                                          

 

Occupation:                                                            

 

Civil status: S___M___W___D___Other_________

 

Spouse's complete name:                                                                              

 

Date and place of your marriage:     __                                                          

 

Parents:                                                father                                           mother

 

Complete name:                                                                                                                        

Date and place

         of birth:                                                                                                                             

 

         of death:                                                                                                                                                    

Date and place of

your parent's marriage:                                                                                                                         

 

                                                                                                                                                                   

 

 

 

Grandparents:                            grandfather                                     grandmother

 

Complete name:                                                                                                                     

Date and place

         of birth:                                                                                                                            

 

   of death:                                                                                                                                                

Date and place of

your grandparents' marriage:                                                                                                                 

 

                                                                                                                                                                      

 

 

 

Signature:                                                                                                                              

 

Date:                                                              

 

Enclosed:        15 $ One year regular membership

                         50 $ One year benefactor membership

                         200 $ Life membership

 

Send completed application with your check made to:

    

      Association des Familles Messier Inc.

      c/o David Messier

            167 avenue Bazin

             Laval, QC

             H7N 4P9

 

     Tél.: 514 827-8544