Member Information PLEASE PRINT NEATLY!

           Name: _______________________________________________
        Address: _______________________________________________
                 _______________________________________________
           City: _______________________________________________
 Province/State: _______________________________________________
Postal/Zip Code: _______________________________________________
        Country: _______________________________________________
           Date: _______________________________________________
   Phone Number: _______________________________________________
          Email: _______________________________________________

                [ ] New Membership             [ ] Renewal

If you live in Canada (all fees are in Canadian dollars):
 One Year Membership:          |    Five Year Membership:
   [ ] Youth (under 16): $15   |      [ ] Youth (under 16):  $60
   [ ] Adult           : $25   |      [ ] Adult           : $100
   [ ] Couple          : $30   |      [ ] Couple          : $125

If you DO NOT live in Canada (all fees are in Canadian Dollars):
 One Year Membership:          |    Five Year Membership:
   [ ] Youth (under 16): $20   |      [ ] Youth (under 16):  $80
   [ ] Adult           : $30   |      [ ] Adult           : $120
   [ ] Couple          : $35   |      [ ] Couple          : $145


Please mail completed form and payment by cheque to:
	Clan Maclean Atlantic 
	c/o Nancy MacGregor (Treasurer)
	44 Meadow Pk. Dr., R. R. #4
	Amherst, NS
	B4H 3Y2