Print This Application, Complete and Mail As Indicated

St. Andrew's Society of New Hampshire, Inc.
Membership Application Form

(Please Print or Type)

Name __________________________________________________________________________

Spouse/Partner Name: ____________________________________________________________

Address ________________________________________________________________________

City __________________________________ State _________ Zipcode: ___________________

Home Phone: __________________ Bus. Phone: __________________ Fax: ________________

Email Address: ___________________________________________________

Optional Genealogical Information

Primary Applicant

D.O.B. __________ Place ____________________

Occupation (current or former, if retired)
__________________________________________

Clan Affiliation/s ___________________________

_________________________________________

Spouse/Partner

D.O.B. _________ Place ____________________

Occupation (current or former, if retired)
_________________________________________

Clan Affiliation/s __________________________

_________________________________________

Children's Names/Ages ________________________________________________________________
____________________________________________________________________________________

Individual Members must be over 18 years of age. Family members include 2 adults living in the
same household and minor children (up to age 18) residing in that household.

Statement: I support the objectives of the St. Andrew's Society of New Hampshire and wish to apply for the
membership class checked below. For a Life Membership, please enclose ten times the yearly fee.
A check is enclosed for the applicable fee.

Signature _____________________________________________ Date ______________________

______ Sponsor $100

______Patron $ 50

______Family $ 25

______Individual $ 15

_____ Donation $____

The St. Andrew's Society of New Hampshire, Inc.
is a 501 (c) (3) organization. Amounts over the
individual or family membership fees go directly
into the scholarship fund and qualify as a
charitable contribution.