Membership form

Surname: ________________________ Given name: ________________________

Address:_________________________ APT #_________ City:__________________

Province/state _____ Country ________________ Postal/zip code:______________

Telephone ___________ Fax__________   Email ___________________________

Surnames:  Spouse ___________________Father ___________________________

Mother __________________ Paternal grand parents_________________________

membership:   new ___ renewal ___

As I become a member of the Association, I agree that my name, and other personal data such as date, place of birth, marriages, will become part of the  genealogical data bank maintained by the Association.

I volunteer my services to serve on committees or to help out on other activities of the Association. yes_________ not presently possible ______

Comments and suggestions: ______________________________________________________________

Signature ________________________  date _____________________

send completed form and  a cheque or money order for  the $20.00 (CA $ for canadian residents and US$20.00 for american residents)  membership fee to the following return address:

Association des descendants de Jean Deslandes dit Champigny

12525 Dansereau Boulevard

Saint-Hyacinthe, Québec

J2R 1R6