DEMANDE D’INSCRIPTION / REGISTRATION FORM

Association des Familles Saint-Pierre-Dessaint inc.

 

Je voudrais devenir membre de l’Association. Ci-joint ma cotisation de 30 $ pour les 12 prochains mois.

I would like to join the Association. Please find enclosed my membership of 30$ for the next 12 months.

 

Renseignements personnels /

Personal informations

Nom / Name : ……………………………………………………………………… Nom de fille / Maiden name: ……………………………………………

Adresse / Address : ………………………………………………………………………………………………………………………………...……………

Ville / City : …………………………………………………………………………………………..Pays / Country : ……………………………………….

Code postal / Postal code :…………………Téléphone / Phone: (………) ………………….. E-mail : ……………………………………………………….

 

REQUÉRANT (E)

APPLICANT

Naissance / D.O.B.: ………………………. Lieu / Place: ………………………………………………………………………………………………………

Nom du conjoint / Spouse’s name : ……………………………………………………………….

Mariage / Marriage: Date / Lieu (Place) : ………………………………. / ……………………………………………………………………………………

 

PARENTS SAINT-PIERRE (OU DESSAINT) DU (DE LA) REQUÉRANT(E) /

APPLICANT’S SAINT-PIERRE (OR DESSAINT) PARENTS

Père / Father : ……………………………………………………………………………………………………………………………………………………

Mère / Mother (nom de fille /maiden name) : ………………………………………………………………………………………………………………….

Mariage / Marriage: Date / Lieu (Place) : ………………………………. / ……………………………………………………………………………………

 

GRANDS-PARENTS /

GRANDPARENTS

Grand-père paternel /Grandfather (father’s side) : ……………………………………………………………………………………………………………..

Grand-mère paternelle /Grandmother (father’s side) : …………………………………………………………………………………………………………

Mariage / Marriage: Date / Lieu (Place) : ………………………………. / ……………………………………………………………………………………

Grand-père maternel / Grandfather (mother’s side) : …………………………………………………………………………………………………………..

Grand-mère maternelle / Grandmother (mother’s side) : ………………………………………………………………………………………………………

Mariage / Marriage: Date / Lieu (Place) : ………………………………. / ……………………………………………………………………………………

Chèque no / Check No : …………………….

 

DATE : …………………………..SIGNATURE : ……………………………………………………………………………..

Envoyer à / Send to: Association des Familles Saint-Pierre-Dessaint 437, rue Mercier, Asbestos, Qc. J1T 3E4