www.4scots.com                 2010                    www.donnachaidh.com

Membership Levels:                                                                               Date: __________________                                               

A. Local Membership:

1. ___ $15.00 Individual Local/State             2. ___  $20.00 Family Local (2 persons/one household).

2a.___$ 5.00 each additional person over age 21 residing in the household of 1 or 2 above.

Additional family member name(s): _________________________________________________________________________________

Total number of additional household memberships: _____

B. International Membership:

1. ___ $40.00 International Dues (One Individual). International # _____________ (Renewal)

C. Donation:

1. ___ I also wish to make a donation to the Local Clan $________ International Clan $ __________

Make checks payable to Clan Society and mail to: Clan Donnachaidh Society of Florida, c/o JoAnne Hudson, Treasurer at: 380 Dickson Ave., Osteen, FL 32764

PLEASE  TYPE  OR  PRINT  CLEARLY:                New 2010 member: ____ or Renewal: _____

Last Name: ____________________________First Name:_________________________________

Spouse/Partner Name_______________________________________(Family Membership Only)

Address: _____________________________________________Apt/Suite/Box Number: ________

City: ________________________________ State: _______________ Zip Code:_______________

E-Mail: _____________________________________________ Clan Surname:________________

Phone: (____) _________________ Fax: (____) ____________Cellular: (____) ________________

Please send clan correspondence by ____ E-mail or ____ US mail

____ I am interested in becoming more involved in the Clan activities or becoming an Officer or Director.

To register a child for Youth Membership:

List children under the age of 21 by full name, age, birthdate, relationship to member, and e-mail address to receive a reproduction of a circa 1800s membership certificate from Scotland:

Child 1:

__________________________________________________________________________________

Child 2: __________________________________________________________________________________

Child 3: __________________________________________________________________________________

Child 4: __________________________________________________________________________________

Additional children may be listed on the back

+++++++++++++++++++++++++++++ Official Use Only +++++++++++++++++++++++++++++

Receipt Number: _______Officer Initials: _____ Funds Received $ ______ Application ID: ____________