Membership Registration Form
Formulaire d'inscription | Bienvenue/Welcome

Name________________________________________________________

Address______________________________________________________

Postal Code___________________________________________________

Telephone / Fax: _______________________________________________

Email: _______________________________________________________

___ Individual $10.00

___ Family (Members under the same roof) $15.00

Names of other family members included

___________________________________________________________________

___________________________________________________________________

Registration effective from date of payment to, and including, August 14, 2004

Signature:_________________________________ Date :____________________

Send with payment to:
Association des Landry de la Nouvelle-Écosse
c/o Richard Landry
Box 168, R R 1
Saulnierville, Nova Scotia, Canada
B0W 2Z0