Membership - Romerikslaget i Amerika

MEMBERSHIP APPLICATION
Print and complete this form and mail to

Linda Curtis, Membership Chairperson
2422 Marquette St.
Eau Claire, WI 54703-1006

Annual Dues are $10.00 for individual or $15.00 for household.

NAME(S)	_________________________________________________
	_________________________________________________

LIST ROMERIKE ANCESTRAL AREA(S):
1.	________________________________________________
2.	________________________________________________
ADDRESS:
	________________________________________________
CITY::	_________________ STATE: ____ ZIP:_____________
TELEPHONE:	___________________ FAX:_____________________
E-MAIL:	______________________________________________

CHECK ALL THAT APPLY:
____	Please send me a sample newsletter.
____	I would like to join. Enclosed is my check payable to
	Romerikslaget

Romerikslaget i Amerika