Application for Membership
in the
Scotch-Irish Society of the United States
Name ________________________________ Address: ___________________________________ ____________________
Street Number Street Apt. Number
________________________________________
Telephone: ________-_____________-________________
________________________________________ _________ _____________-_______________
City State Zip Code
e-mail address: ___________________________________
Ancestry: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature:___________________________________________ Date:___________________________
Application fee: $_____________
Annual Dues: $_____________
Total: $_____________
Please include the total amount shown above with application and mail to:
Corresponding Secretary