REQUEST FOR
MEMBERSHIP
ASSOCIATION des familles GOSSELIN inc.
associationfamillesgosselin@hotmail.com
My identification:
Name: ____________________________ First
name: ___________________________
Address: _______________________________________________________________
City :_____________________________ State or Prov :_________________________
Postal code or Zip code : ___________________________________________________
Phone
number: ( )_________________ Second number : ( )___________________
FAX:
( ) ________________________ e-mail: ______________________________
Birth: day:______month:_______year :______place :___________________________
Profession: ______________________________________________________________
Occupation: _____________________________________________________________
My membership: my
cheque is enclosed
I wish to join the association as:
Regular member: ( ) one year
$15.00 two
years $25.00
Lifetime member: ( ) $ 200.00
Governor member: (
) $ 500.00 once for life
Identification of
my wife/husband:
Name: ____________________________ First name: ___________________________
Birth: day______ month ______
year ______ place _____________________________
Profession: ______________________________________________________________
Occupation: _____________________________________________________________
Our marriage: day_____month_____year_____place____________________________
I hereby authorize the use of personal informations revealed in this document for the genealogy
searches and the making of the Genealogic Dictionary of Gosselin
families. All informations were given to the best of
my knowledge.
__________________________________________
Signature
SEND (with your payment) to:
1647, Chemin Royal, Saint-Laurent. Île d’Orléans,
(Québec) G0A 3Z0