Membership Form for
The Association of Gagne-Bellavance Families in America

New Membership(  ) or Renewal  (  )
If renewal, your membership card number:_______

Last name:______________________________________________________
First name:______________________________________________________
Spouse's last name:________________________________________________
Spouse's first name:________________________________________________
Address:________________________________________________________
City:__________________________________________________________
Postal code:______________Country:________________________________
Phone Home:_____________________Work:_________________________
Date and birth-place:______________________________________________
Date and marriage-place:___________________________________________
E-mail:_________________________________________________________

My parents

Father's last name: ________________________________________________
Father's first name:________________________________________________
Mother's last name:________________________________________________
Mother's first name:________________________________________________
Date and place of marriage:__________________________________________

My spouse's parents

Father's last name: ________________________________________________
Father's first name:________________________________________________
Mother's last name:________________________________________________
Mother's first name:________________________________________________
Date and place of marriage:__________________________________________

My grandparents

Grandfather's last name: _____________________________________________
Grandfather's first name:_____________________________________________
Grandmother's last name:____________________________________________
Grandmother's first name:____________________________________________
Date and place of marriage:___________________________________________

My spouse's grandparents

Grandfather's last name: _____________________________________________
Grandfather's first name:_____________________________________________
Grandmother's last name:____________________________________________
Grandmother's first name:____________________________________________
Date and place of marriage:___________________________________________

My great-grandparents

Great-grandfather's last name: _____________________________________________
Great-grandfather's first name:_____________________________________________
Great-grandmother's last name:____________________________________________
Great-grandmother's first name:____________________________________________
Date and place of marriage:_______________________________________________

My spouse's great-grandparents

Great-grandfather's last name: _____________________________________________
Great-grandfather's first name:_____________________________________________
Great-grandmother's last name:____________________________________________
Great-grandmother's first name:____________________________________________
Date and place of marriage:_______________________________________________

Membership Fees (Canadian Dollars)

Regular Member: $20.00/year

Spouse of a regular member $5.00/year

Six Year Membership Subscription: $100.00

Spouse of a regular member 6 years $25.00

Twelve Year Membership Subscription: $200.00

Spouse of the regular member 12 years $50.00

Check or money order payable to:

Association des Familles GAGNÉ-BELLAVANCE d'Amérique Inc.

714, Rue de la Beauce

Québec (QC), Canada G1X 2S7

Benefits of membership:

Membership card, Annual meeting,

Bulletin three times annually (Most text is in French but some articles are in English.)

Family Tree:

$20.00 in addition to membership fees.

Residents of the United States should pay the Family Tree fee in American dollars.

N.B. Printed from the website http://www.gagnier.org

Rev. John F. Gagnier