Membership Form

[For Gift Memberships, fill out recipient's info except for Gift Questions at the end.]

First Name *

M.I.

Last Name *

Address *

Apt no.

ZIP *

City *

State/Province *

Country *

Phone *

E-mail

Date *

mm/dd/yyyy

Please complete form here, print & mail with dues to:
NALF c/o Dick Leavitt
50 Woodland Road
Pownal, ME 04069

Yearly membership expires 12 months from date. Cards will be issued for Life Members.

Date of Birth

Place of Birth

Mother's name

Father's name

Grandmother

Grandfather

Lineage/Generation (if known)

How did you find the NALF site? [If this is a gift membership, just answer "current member".]

I would like the following membership: *

		Annual (Enclose $10.00)
		Annual Sustaining (Enclose $15.00)
		Lifetime, 50-55 years old (Enclose $200.00)
		Lifetime, 56-60 years old (Enclose $170.00)
		Lifetime, 61-65 years old (Enclose $135.00)
		Lifetime, over 65 years old (Enclose $100.00)

If this is a gift membership, please include gift note message below [such as "I hope you enjoy this membership as I have. Love Aunt Susan"]

If this is a gift membership, please include giver's name and email address or phone number below.

Would you like to receive our genealogist's E-news [3-4 issues yearly]? Must provide email address. No additional charge. *

		Yes
		No

PLEASE PRINT THE FORM BEFORE CLICKING "SUBMIT" BUTTON.

* = Input is required