KIROUAC FAMILY ASSOCIATION INC.

MEMBERSHIP FORM

Please print, complete and return by post

New membership [___] or  Renewal [___]

Identification:

Family name at birth: _________________________ Surname (s):__________________________

Birth: D/M/Y: ____  /_____ / _____ Place: _____________________________________________

Address: Number: ______ Appt:_____ Street: ___________________________________________

City: ________________________________________ Prov./State: ___________________________

Country:___________________________ Postal Code/Zip Code: ___________________________

Telephone: Residence: ____________________________ Office: ____________________________

E-Mail: ______________________________________________________________________________

K/rouac ancestry : Yes (  )  No (  )

Occupation : ____________________________________________________________ Retired: [___]                                          

Annual Membership Fee:  

            Regular Member: $22 Can. / USA

            Benefactor: $27 Can. / USA

            Member Overseas : $ 30. Can

I wish to receive the quarterly bulletin LE TRÉSOR in French (___)  in English (___)

Please make out your cheque or Money Order to:

 ASSOCIATION DES FAMILLES KIROUAC INC

And mail it to: 

ASSOCIATION DES FAMILLES KIROUAC INC.
c/o Mr. René Kirouac

3782 Chemin Saint-Louis, Québec (Québec) Canada

G1W 1T5