Gold Country Celtic Society

NevadaCountyCelticClub.org

Application for Membership

Name:_______________________________________________________________________

Spouse’s Name:_______________________________________________________________

Mailing Address:_______________________________________________________________

City/State/Zip:_________________________________________________________________

Telephone: [Home]__________________________[Work]_____________________________

E-mail Address:_______________________________________________________________

Business or Occupation:________________________________________________________

Hobbies:_____________________________________________________________________

Clan Name:___________________________________________________________________

Date of Birth: [Husband]_____________________[Wife]______________________________

Date of Marriage:______________________________________________________________

Family Members

Name:_________________________________Relationship:___________________________

Name:_________________________________Relationship:___________________________

Name:_________________________________Relationship:___________________________

Name:_________________________________Relationship:___________________________

ANNUAL MEMBERSHIP DUES

(check one)

[ ] $15 Single Senior Citizen (60+) [ ] $25 Senior Citizen Couple (60+)

[ ] $20 Adult [ ] $30 Adult Couple/Family

Name badges free for new members

Signed:________________________________Dated:_________________________________

Mail this completed form with your check to: Gold Country Celtic Society, POB 23, Nevada City, CA 95959-0023

Questions? Contact: Franca Jones, Membership Chairperson, (530) 878-6587

Our regular meetings are the 4^th Wednesday of the month at VFW Post 2655, 415 Pine St. in Nevada City at 6:00 p.m.

Please join us for a potluck dinner and entertainment.