SUBSCRIPTION FORM

Welcome

Name :
Birth place :
Date of birth :
Father's name :
Maiden name of mother :
Husband name :
Wedding place :
Wedding Date :
Children under 18 years of age :	Oui Non
If yes, how many ?	1 2 3 4
Name of 1st child :
Name of 2d child :
Name of 3rd child :
Name of 4th child :
Adress :
City :
Province :
Postal code :
Telephon number :
Email address :
Type of membership :	yearly (20 $) 8 years (150 $) life (400 $)

Included is a cheque in the amount of ______$ made to

the Faucher and Foucher's Association (Châteauvert, Saint-Maurice).
* Membership cover also the wife and all children under 18 years of age.

Signature : ________________________________________

Print this form and send it to the following adress :
(don't forget to include your payment)

Faucher and Foucher's Association (Châteauvert, Saint-Maurice).

C.P. 10090, Succ. St-Foy
Ste-Foy (Québec) G1V 4C6.