Join our Association
Complete and return this Membership
Application form
Date: __________________
I wish to join the “Association des
familles Cheval dit St-Jacques d’Amérique”.
I subscribe the amount of:
________________
$20 CDN or $15 US for one year,
$35 CDN or $25 US for two years or
$200 CDN or $145 US for a life
membership.
Surname:
____________________________________________
Name:
_________________________________________
Address:
____________________________________________
City and province or State:
_________________________________________
Postal Code/Zip:
_________________________________________
Phone: Home:
_________________________Office: ________________________
Fax:
___________________________________________
E-Mail:
_________________________________________
Personal Web Site:
______________________________
I authorize the publication of my name,
address, phone and fax numbers, as well as my E-Mail in lists
of members:
yes:
_________________________________________ (signature)
no:
__________________________________________ (signature)
Please use the following format for dates:
year-month-day
e.g.: June 20, 1940 =
1940-06-20
Date of birth/baptism:
________________________ / ________________________
Place of birth/baptism:
________________________ / ________________________
Date of marriage:
_________________________________________
City and parish of marriage:
_________________________________________
Father:
_________________________________________
Mother:
_________________________________________
Date of marriage:
_________________________________________
City and parish of marriage:
_________________________________________
Grandfather (Paternal):
_________________________________________
Grandmother (Paternal):
_________________________________________
Date of marriage:
_________________________________________
City and parish of marriage:
_________________________________________
Grandfather (Maternal):
_________________________________________
Grandmother (Maternal):
_________________________________________
Spouse
Surname:
_______________________________________
Name:
_________________________________________
Father:
________________________________________
Mother:
_________________________________________
Children
Surname
Name
Date of birth/baptism Place
birth/baptism
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please make your cheque payable to:
Association des familles Cheval dit
St-Jacques d’Amérique
Send this form with your payment to:
Association des familles Cheval dit
St-Jacques d’Amérique
Alphonse St-Jacques, President and
treasurer
815, Muir, Apt 407
Saint-Laurent, QC
H4L 5H9 CANADA
Do not hesitate to distribute copies to
your relatives.
