Member # *_________ Date: *______
New Membership _____ Renewal * ________
 
 

NAME: *______________________________ Print as you wish on certificate:

ADDRESS: *___________________________
CITY, STATE, ZIP:* _____________________
PHONE # *(_____) __________________
EMAIL ADDRESS:* _____________________ OCCUPATION:____________________
SPOUSE’S NAME: _____________________

NAME AND RELATION OF EARLIEST KNOWN ANCESTOR AND PLACE/DATE
OF BIRTH:
________________________________________________________________
________________________________________________________________
Membership Dues: $20.00 _____
Annual ; $150.00 Lifetime _____
Send completed form and check payable to Clan Anderson Society, Ltd.
c/o Robert B Anderson
3107 Country Club Drive
Valdosta, GA 31602
For renewals fill only areas marked with *
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Received _____________ Posted ________________ Deposited ____________ To Genealogist ___________ ToNewsletter _______