MEMBERSHIP FORM
(Please make sure to print both pages)

New member: Renewing: Member number:
 Name:                                                                             First name:
 Adress:
 Town/City:                                                       Province/state:                                      Postal code/zip:
 Res phone:  (          )                                                         Office phone:  (          )
 E-mail:


FEES

$25.00         Annual fees (including spouse)                                                       $____________

$300.00        Lifetime membership for 60 and older                                             $____________

                     Donations                                                                                          $____________

                                                                  Total amount  :                    $____________



 

 

         Print and return to:          

Association des Séguin d'Amérique
15, rue Jacqueline,
Rigaud, Québec, Canada
J0P 1P0

Please print and fill in the 2 pages.
 

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