Clan Fergusson Society of North America

APPLICATION FOR MEMBERSHIP

I hereby apply for membership (or reinstatement of former membership) in the Clan Fergusson Society of North America as a: Enclosed

_____Reinstated Member $25.00 $__________________

(include membership number if known)

_____Regular Member $30.00 $__________________

(includes spouse and children under 18)

_____Associate Member $30.00 $__________________

(not a FERGUSSON/SEPT but have a genuine interest in CFSNA)

_____Life Member (under age 60 - $500; age 60 and over - $300) $__________________

Date _________________ Signature _____________________________________________________________

Name (please print) Mr. Mrs. Ms. ________________________________________________________________

Home Address _________________________________________________Phone ________________________

(street & number) (include area code)

______________________________________________________________Zip __________________________

(city, sate or province)

Date of Birth_______________ Place of Birth_______________________________________________________

Occupation ___________________________________________ e-mail ________________________________

Business Address ____________________________________________________________________________

_____________________________________________________ Business Phone________________________

Spouse Full Name (with maiden name if applicable) _________________________________________________

Names and birth dates of children ________________________________________________________________

If your surname is not one of those eligible for membership, please explain your relation to a direct ancestor of eligible name:

Sponsor __________________________________ CFSNA Secretary ___________________________________

Please list on the reverse side the names and addresses of others who might be interested in joining the

Clan Fergusson Society of North America