Celtic Heritage Society of the Permian Basin
 
Membership Form

DATE: _______________	MEMBERSHIP FOR CALENDAR YEAR: __________

NAME: ________________________________	SPOUSE: _____________________

ADDRESS: _____________________________________________

CITY/STATE: _________________________________	ZIP CODE: ________________

HOME PHONE: ____________________	 WORK PHONE: ________________________  

FAX: ________________________		EMAIL: ________________________________

CHILDREN NAMES: ________________________  CLAN: _________________________

			   ________________________

			   ________________________


ANNUAL DUES:	Single Person-		$10.00 per calendar year
			Couple or family-	$15.00 per calendar year

MAKE CHECKS PAYABLE TO:	Celtic Heritage Society of the Permian Basin
MAIL CHECKS TO: 	Celtic Heritage Society of the Permian Basin
				P.O. Box 7144
				Midland, Texas 79708-7144

PLEASE CHECK WHERE APPLICABLE:

______	Would you be willing to serve as the Chieftain (President), Cadet (Vice-President) 
or Sporran (Treasurer) 

______	Would you be willing to serve on the Council (eight members)

______	Would you be willing to serve as Recording Scribe (Secretary) or Corresponding 
Scribe (Corresponding Secretary)

______	Would you be willing to be on the nominating committee

______	Would you be willing to serve on various committees from time to time as 
deemed necessary by the Chieftain and/or the Council
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