Membership form or renewable to Association des Drouin d'Amérique

                                                  New joining : complete Block A and Block B                                       

                                                     Renewable (no change) : go to Block B

      Block A ================================================================

Last name : _________________________________ First name : _________________________________

Address : __________________________________________________City : ________________________

Province/State : _________________________ Country : ________________ Zip code : ______________

Phone : _________________________ E-mail : _______________________________________________

Father : ___________________________________ Mother : _____________________________________

Their Place and marriage date : ____________________________________________________________

Your spouse's name : ______________________________________________

     Block B ================================================================

Last name : _____________________ First name : _______________________ Member number : ____

To become a member ($25) :           Annual renewable ($20):          3 years renewable ($50) : 

Signature : ______________________________________ Date : ____________________ 

Fill the membership form, join your check made to Association des Drouin d'Amérique and mail to:

                                                        Association des Drouin d'Amérique

                                                        142 Joseph-Bouchette Street

                                                        Boucherville (Quebec) Canada  J4B 4H1

                                                                                                                                       2007-09-13