BEING A MEMBER KEEPS THE MEMORY OF OUR ANCESTORS ALIVE.

ALL NEW MEMBERS RECEIVE THEIR CERTIFICATE OF LINEAGE.

LAST NAME AND FIRST NAME:..................................................................................................

ADDRESS:.......................................................................................................................................

CITY:.......................................................STATE..................

POSTAL CODE:..............................

COUNTRY:.............................................................TELEPHONE:..(..........).............-....................

My parents' name:.............................................................................................................................

were married at: ..........................................................................Date:.............................................

My grandparents' name:....................................................................................................................

were married at:...........................................................................Date:.............................................

Enclosed is a check for: $................to become a member. (Your cancelled check will serve as your receipt.)

We thank you in advance for your gesture of solidarity.

Regular member: $15.00 - Benefactor member: $30.00

Make check payable to: "DESCENDANTS DE LAZARE BOLLEY" and send with completed form to:

ALL NEW MEMBERS RECEIVE THEIR CERTIFICATE OF LINEAGE.