Join Clan Mackintosh NA

Clan MacKintosh of North America Membership Application from Kenneth McIntosh Convenor for Kentucky

APPLICANT:

Class of Membership: Family__ Individual__ Associate Family__ Associate Individual__ Name:_________________________________________________________ Address:_______________________________________________________ _______________________________________________________

City:________________ State/Prov:___________ Zip:______-_______

IF BILLING ADDRESS IS DIFFERENT, PLEASE ENTER BILLING ADDRESS ON THE BACK SIDE OF THIS FORM.

Phone: Residence:(____)-____-______ Business:(____)-____-______ Fax:(____)-____-______ Email:________________________________ Occupation:____________________________________________________

Place of Birth:_________________________ Date of Birth:__________________

Spouse’s Name:_________________________________________________ Occupation:____________________________________________

Place of Birth:_________________________ Date of Birth:___________________

Children under 18:___________ __ , ___________ __ , ___________ __ , __________ __ , ___________ __ , ____________ __ , ____________ __ , ____________ __ , ____________ __

(Please list age with name of each child, Thank you.)

Clan/ Sept Affiliation: Paternal:_________________________________________

Maternal:_________________________________________ Marriage:_________________________________________

ARE YOU INTERESTED IN BECOMING ACTIVE IN ANY OF THE FOLLOWING CLAN ACTIVITIES? CLAN TENT: ___ SCOTTISH GATHERINGS:___ NEWSLETTER:___ CLAN OFFICER:___ Other

Interests:____________________________________________________________ Amount Paid: $___________

Date:____________ Signature:______________________________

FORWARD APPLICATION & PAYMENT TO: Albert P. McIntosh, Treasurer 69-C4 Furnace Avenue Stafford Springs, CT 06076 MAKE CHECKS PAYABLE TO: CLAN MACKINTOSH OF NORTH AMERICA Family $15.00 Individual $10.00 Associate Family $15.00 Associate $10.00 Annual Membership Dues Per Fiscal Year (January through December) Note: New members signing up during the first six months of the fiscal year will pay the prorated membership dues for the remaining months of that year. New members signing up during the last six months of the year will pay the prorated membership dues for the remaining months of that year PLUS ONE YEARS DUES. Proration rate is $ .84 per month for individual and $1.25 per month for Family. Any new member may pay up to 5 years additional dues. All membership dues are payable in January.


	Join Clan Mackintosh NA Clan MacKintosh of North America Membership Application from Kenneth McIntosh Convenor for Kentucky APPLICANT: Class of Membership: Family__ Individual__ Associate Family__ Associate Individual__ Name:_________________________________________________________ Address:_______________________________________________________ _______________________________________________________ City:________________ State/Prov:___________ Zip:______-_______ IF BILLING ADDRESS IS DIFFERENT, PLEASE ENTER BILLING ADDRESS ON THE BACK SIDE OF THIS FORM. Phone: Residence:(____)-____-______ Business:(____)-____-______ Fax:(____)-____-______ Email:________________________________ Occupation:____________________________________________________ Place of Birth:_________________________ Date of Birth:__________________ Spouse’s Name:_________________________________________________ Occupation:____________________________________________ Place of Birth:_________________________ Date of Birth:___________________ Children under 18:___________ __ , ___________ __ , ___________ __ , __________ __ , ___________ __ , ____________ __ , ____________ __ , ____________ __ , ____________ __ (Please list age with name of each child, Thank you.) Clan/ Sept Affiliation: Paternal:_________________________________________ Maternal:_________________________________________ Marriage:_________________________________________ ARE YOU INTERESTED IN BECOMING ACTIVE IN ANY OF THE FOLLOWING CLAN ACTIVITIES? CLAN TENT: ___ SCOTTISH GATHERINGS:___ NEWSLETTER:___ CLAN OFFICER:___ Other Interests:____________________________________________________________ Amount Paid: $___________ Date:____________ Signature:______________________________ FORWARD APPLICATION & PAYMENT TO: Albert P. McIntosh, Treasurer 69-C4 Furnace Avenue Stafford Springs, CT 06076 MAKE CHECKS PAYABLE TO: CLAN MACKINTOSH OF NORTH AMERICA Family $15.00 Individual $10.00 Associate Family $15.00 Associate $10.00 Annual Membership Dues Per Fiscal Year (January through December) Note: New members signing up during the first six months of the fiscal year will pay the prorated membership dues for the remaining months of that year. New members signing up during the last six months of the year will pay the prorated membership dues for the remaining months of that year PLUS ONE YEARS DUES. Proration rate is $ .84 per month for individual and $1.25 per month for Family. Any new member may pay up to 5 years additional dues. All membership dues are payable in January.