Friends of Marilyn Adams Membership Application

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Please print out and complete this form.

JOINT MEMBERSHIP APPLICATION
Friends of Marilyn Adams & 7th Town Historical Society
Box 35, 528 County Road 19, Ameliasburg, Ontario, Canada K0K 1A0
Membership runs for 12 months from the end of the quarter in which you join.

Please PRINT or TYPE and remember to sign the form.

NAME
ADDRESS:
CITY:	PROV. / STATE:	POSTAL CODE / ZIP:
TELEPHONE:	E-MAIL:
YOU MAY E-MAIL MY COPY OF THE "QUINTE KIN" NEWSLETTER YES ____ NO ____
NEW ___ RENEWAL ___ 7th TOWN # _________ FMA # _________ I am interested in volunteering ___		AMOUNT
FRIENDS OF MARILYN ADAMS (FMA) (Canadian tax receipt will be issued) * $6.00 of the FMA fee is a donation under the 10 year rule of the Canada Revenue Agency and goes to the FMA Trust.		* $18.00
7th TOWN HISTORICAL SOCIETY (Canadian tax receipt will be issued)		$5.00
Donation to General Fund (Canadian tax receipt will be issued)
Donation to Trust Fund (Canadian tax receipt will be issued) Donations to the TRUST FUND are made under the Canada Revenue Agency Ten Year Rule
Donation to Library Acquisition Fund (Canadian tax receipt will be issued)
Out of Canada, please send in US dollars... TOTAL
Your signature (below) is required by the Canada Revenue Agency and allows the $6.00 of the Friends of Marilyn Adams fee (FMA) and all other donations to go into the Trust Fund
SIGNATURE: (Required by Canada Revenue Agency under the 10 year rule) _____________________________________________________________________________________________
Please make cheque payable to: 7th TOWN HISTORICAL SOCIETY Mail to: Box 35, 528 County Road 19, Ameliasburg, Ontario, Canada K0K 1A0
PLEASE LIST 6 SURNAMES YOU ARE RESEARCHING Please include these names, my name, my postal address and my email address in the annual list of surnames being researched (sent out in December) YES ______ NO _____
1.	4.
2.	5.
3.	6.